OCD and Psychological Management

Government of India
CENTRAL INSTITUTE OF PSYCHIATRY

OCD AND PSYCHOLOGICAL MANAGEMENT
Date – 1st December 2011
CHAIRPERSON – Ms. Deyashini Lahiri

PRESENTER – Ms. Susmita Sitaram
DISCUSSANT – Ms. Nidhi Gupta
PRESENTATION DISCUSSION
- Introduction - Introduction
- Historical Overview - Psychological Theories of OCD
- Nature of Obsessional Experience - Rating Scales & their efficacy in OCD
- OCD and Comorbidity - Efficacy of Various Psychological
- Theoretical Models of OCD Therapies in OCD
- Assessment of OCD - Special considerations in Exposure and
- Therapeutic Models of OCD Response Prevention (ERP)
- Managing children with OCD - Cognitive vs. Behavior Therapy for OCD:
- OCD and Family Management What works best for whom?
- Management of Disorders within - Changes in brain mechanism after
the Obsessive Compulsive Spectrum psychotherapy
- Maintaining treatment gains and - Management of childhood OCD
managing relapse - Combining Medication and Psychotherapy
- Treatment Resistant OCD - Critical Issues in OCD: Spectrum and
- Conclusion comorbidities
- Special Issues in Treatment
- Newer trends in Psychological treatment of
OCD
- CIP Studies
- Conclusion
INTRODUCTION
Leonardo Di Caprio, a Golden globe award winning American actor who garnered world-wide fame for
his role in Titanic has to force himself not to step on every chewing gum stain when walking along. He
fights urges to walk through a doorway several times, because he doesn‘t want his condition taking over
his life. Obsessive thoughts and compulsive urges are part of the normal feedback and control loop
between our thoughts and our actions. It is only when these obsessive thoughts become so intense and
frequent and these compulsive rituals become so extensive that they interfere with an individual‘s
functioning that the diagnosis of obsessive compulsive disorder (OCD) is made.
HISTORICAL OVERVIEW
OCD has a long history with its initial attribution to possession by an evil and exorcism as the sole
treatment option. Esquirol (1838) was the first to argue that, since his patients were aware that their
obsessions were irresistible, they possessed a certain degree of insight. Thus, the emergence of ‗neurosis‘
began during the early 1800s, a notion further developed when Morel described OCD as a ‗disease of
emotions‘. By the beginning of the 20th century, the view of the obsessive compulsive neurosis has shifted
toward a psychological explanation. Janet (1903) was the first to put forward the psychological
perspective of obsessive-compulsive neurosis according to which such patients possessed an abnormal
personality with features such as anxiety, excessive worry, lack of energy, doubting that could possibly be
treated with the help of behavior principles (Jenicke et al., 1998). With Freud‘s publication in 1909,
obsessive and compulsive actions were seen as a result of unconscious conflicts, thoughts and actions
being isolated from their emotional components.
DEFINITION AND NATURE OF OBSESSIONAL EXPERIENCE (Krebs & Heyman, 2010)

OBSESSIONS COMPULSIONS
Unwanted, recurrent and persistent Repetitive behaviors or mental acts that are
Definition intrusive thoughts, impulses or images driven by obsessions or rigid rules.
that cause marked distress.
- Contamination - Washing and Cleaning

Common - Aggression - Checking
Themes - Sexual - Repeating
- Religious - Reassurance Seeking
- Ordering
OCD and Psychological Management. Lahiri, D., Sitaram, S. and Gupta, N. Page 1
OCD AND COMORBIDITY
Persons with OCD are commonly affected by other mental disorders. Other common comorbid
psychiatric diagnoses in patients with OCD include depressive disorder, alcohol use disorders,
generalized anxiety disorder, specific & social phobia, panic disorder, and personality disorders. OCD
exhibits a superficial resemblance to obsessive-compulsive personality disorder as well as others in the
spectrum. (Sadock & Sadock, 2007)
THEORETICAL MODELS OF OCD
Biological Models (Sadock & Sadock, 2007)
Genetics Relatives of probands with OCD consistently have a three- to fivefold higher
probability of having OCD or obsessive-compulsive features than families of
control probands. Twin studies have also produced findings attesting to the
genetic aggregation in OCD, with concordance rates higher in monozygotic
twins (65%) than dizygotic twins (15%).(Pauls et al., 1991).
Neurotransmitter The most popular neuro-chemical model of OCD involves deficits in serotonin
neurotransmitter system (Goodman et al., 1992).
Immunology There exists a positive link between streptococcal infection and OCD.
streptococcal infection can cause rheumatic fever, and approximately 10 to 30
percent of the patients develop Sydenham's chorea and show obsessive-
compulsive symptoms.
Brain-imaging These indicate altered functioning in the neurocircuitry between orbitofrontal
techniques cortex, caudate and thalamus.
Neuropsychological Research suggests impairments in visual-spatial and visuo-constructional
Deficits ability and frontal lobe related executive functions. (Zielinski et al., 1991)
Psychological Models
Psychodynamic Model
A number of interesting hypotheses are raised by theorists in that area. Nemiah and Uhde noted that, from
a psychoanalytic perspective, three major psychological defense mechanisms determine the form and
quality of obsessive-compulsive symptoms and character traits: isolation, undoing, and reaction formation
(Kaplan & Sadock, 1995)
Isolation is a defense mechanism that protects an individual from anxiety provoking affects and impulses.
Under ordinary circumstances, an individual experiences in consciousness both the affect and the imagery
of an emotion-laiden idea, whether it be fantasy or the memory of an event. When isolation occurs, the
affect and the impulse from which it derives are separated from the ideational component and pushed out
of consciousness. Thus, the person might think about violence without experiencing anger, isolating
himself from the affect associated with the distressing situation.
Undoing refers to compulsive act that is performed in an attempt to prevent or undo the consequences
that the patient irrationally anticipates from a frightening obsessional thought or impulse. The compulsive
act is the manifestation of a defensive operation aimed at reducing anxiety and at controlling the
underlying impulse that has not been sufficiently contained by isolation. For example, people with
blasphemous thoughts might engage in excessive praying and cleaning rituals.
Reaction Formation involves manifest patterns of behavior and consciously experienced attitudes that
are exactly the opposite of underlying impulses. Often these patterns appear to an observer as highly
exaggerated and sometimes quite inappropriate. Reaction formation is thought to be responsible for many
of the personality traits characterized by control that make up some elements of obsessive compulsive
personality disorder. For example, somebody who was obsessed with thoughts of harming her children
might become a supermom.
Changes in the superego – Psychoanalytic view of OCD has been described as regression to a
developmentally earlier stage of infantile superego, the harsh, exacting, punitive characteristics of which
now reappear in the mental functioning of neurotic adults. The appearance of symptoms of OCD is
attributed to a defensive regression of the psychic apparatus to a pre-oedipal anal-sadistic phase, with the
consequent emergence of earlier modes of functioning of the ego, superego and id. These factors along
with specific ego defenses produce the clinical symptoms of obsessions and compulsions.
Behavioral Model
The behavioral theory of OCD was based on learning theory; particularly the two-factor model of fear and
avoidance presented by Mowrer (1939, 1960). This model proposed that normal intrusive thoughts,
images, or impulses become associated with anxiety via classical conditioning so that when an intrusive
thought occurs, anxiety increases. The person then learns, via operant conditioning, to reduce obsessional
anxiety by escaping or avoiding stimuli that evoke obsessional thoughts. Thus, compulsive behavior is
performed to escape from obsessional anxiety and is negatively reinforced by the reduction in anxiety that
it engenders (Abramawitz & Houts, 2005).
Cognitive Models
Three cognitive-behavioral models are presented below. Although they diverge somewhat in emphasis,
the various models are more similar than they are different. In particular, the fundamental premise of each
model is that obsessional problems occur as a result of the appraisal of otherwise normal intrusive
thoughts, images, and impulses as highly significant or threatening thus leading to an escalation in the
frequency and intensity of obsessive intrusive thoughts (Clark et al., 2003).
Salkovskis‘ Cognitive-Behavioral Theory of OCD

In 1985, Salkovskis proposed a cognitive-behavioral analysis of OCD according to which people with
obsessional problems appraise normal intrusive thoughts, images, and impulses as an indication that (a)
harm to themselves or others is a particularly serious risk and (b) they may be responsible for such harm
(or its prevention) (Salkovskis & McGuire, 2003). It is this specific interpretation of intrusive cognitions
that is believed to link such intrusions with associated discomfort and urges to perform neutralizing
behavior such as compulsive rituals, to reduce this discomfort. According to this account, successful
completion of neutralizing reduces perceived responsibility, alleviates distress, and is almost inevitably
accompanied by the absence of the feared consequence and the failure to disconfirm faulty appraisals.
Hence the association among intrusion, appraisal, and neutralizing is strengthened. Factors proposed to
interact with these experiences include criticism and blame and rigid codes of conduct, situational
increases in responsibility (eg, birth of a child/having an infant; Abramowitz, Schwartz, & Moore, 2003),
and certain coincidental events such as wishing someone is dead and finding out that they are the next
day. (Abramawitz & Houts, 2005) (Refer to Appendix 1)
Rachman‘s Cognitive Theory of Obsessions

Rachman (1997) proposed a cognitive theory of obsessions hypothesizing that ―obsessions are caused by
catastrophic misinterpretations of the significance of one‘s thoughts (images, impulses)‖. This leads to the
prediction that obsessions will persist as long as these misinterpretations continue, and they will diminish
when the misinterpretations are weakened. The misinterpretations are not limited to responsibility
appraisals, but can include other catastrophic interpretations such as thought action fusion, thought event
fusion and thought object fusion.
Thought Action Fusion The belief that having an intrusive The belief ―if I think about killing my
(TAF) thought increases the likelihood that child, this is almost as bad as actually
a specific adverse event will occur killing a child.
Thought Event Fusion Beliefs such that thinking about an If I think about someone else falling
(TEF) event might mean that the event has ill, it makes it more likely that they
happened or will happen. will become ill.
Thought Object Fusion The belief that thoughts can One patient described how he
(TOF) contaminate objects. believed that having a thought of a
pedophile while he was shaving had
the power to transfer that thought into
his razor such that future shaving
would increase the risk of becoming a
pedophile
Avoidance or covert neutralization provides temporary relief from obsessional distress. However,
Rachman (2002) proposed that attempts to check for safety produce adverse affects that turn the checking
behavior into a self-perpetuating mechanism as follows:
1. An unsuccessful search for certainty that probability of harm has been reduced or removed.
2. Repeated checking tarnishes memory of checking which makes achievement of certainty even less
likely.
3. The perceived probability of harm (and possibly the seriousness of harm) is elevated when the person
feels responsible.
4. Responsibility increases after they have checked for safety. (Refer to Appendix 2)
Purdon and Clark‘s Cognitive Theory Emphasizing the Importance of Thought Control
Purdon and Clark (1999) have developed a model in which (a) faulty beliefs about the importance of
controlling one‘s thoughts and (b) negative misinterpretations of the consequences of failure to control
unwanted intrusive thoughts are considered critical to the pathogenesis of obsessional problems.
Examples of faulty beliefs include ―I must control every thought that enters my mind, especially negative
ones,‖ ―losing control of thoughts is as bad as losing control over behavior,‖ ―I would be a better person if
I could control unwanted thoughts,‖ and ―control over thoughts is an important part of self-control‖
(Purdon & Clark, 2002). It is proposed that such beliefs result in (a) heightened vigilance for the
occurrence of the very intrusive thoughts to be controlled and (b) active resistance to such thoughts, for
example, by attempting to suppress them. This model of the development of obsessions is based on the
work of Wegner and colleagues (Wegner et al., 1987, Wegner, 1989) who found that deliberate
suppression of a neutral (―white bears‖) thought was associated with an increase in its frequency during
and after thought suppression. Moreover, failed attempts to control unwanted thoughts may evoke more
catastrophic beliefs about the responsibility and personal significance concerning such thoughts. For
example, ―if I try and still can‘t control this terrible thought, it must mean the thought is really important
and I must do something about it.‖ (Abramawitz & Houts, 2005) (Refer to Appendix 3)
ASSESSMENT IN OCD
Rating Scales used in OCD

Several scales are available to assist in the diagnosis of OCD and measurement of treatment efficacy.
(Details in the Appendix 4)
Findings on Psychological Assessment (Marnat, 2003)
MMPI MCMI DAPT Rorschach TAT

Elevations on  Heavy lines  High R Obsessive
High Scores the following  Shading  High Dd preoccupations are
on Scale 7 - scales:  Tall and thin  RT is greater quite apparent as
Psychasthenia  Compulsive neck  Form quality the subject is
 Anxiety  Ape like good concerned about
presentation  Absence of C every minute
of the head. responses detail. In addition,
 Shading they often
responses comment on the
present picture such as
―the furrows are
 F+% high
not straight.‖ etc.
 Wider content
category
 High P
 Use of contam
 OBS index
THERAPEUTIC APPROACHES IN OCD

Research over the past two decades has confirmed that obsessive-compulsive disorder (OCD), once
considered treatment refractory, is now amenable to treatment.
Common Modes of Treatment
Behavior therapy
Behavior therapy is based on the learning theory underlying the acquisition and maintenance of OCD.
Behavior therapy is composed of mainly two procedures of exposure and response prevention.
Exposure and Response Prevention

Exposure is a behavioral technique used to confront patients with feared stimuli, objects, or situations
with the goal of ultimate reduction of unpleasant reactions, and anxiety. Exposure can be of two kinds:
 In ―in vivo‖ exposure, the actual anxiety producing stimuli is presented to patients until anxiety is
reduced to a tolerable level.
 In imaginal exposure, anxiety provoking stimuli are presented in imagination only, until feared
stimuli lose their fear-provoking properties.
Stekee et al (1982) hypothesized that OCD patient with extreme avoidance of fear of catastrophic
consequences who were unable to tolerate in vivo exposure, or for whom in vivo exposure is not feasible
for practical reasons, might benefit from imaginal exposure and more readily agree to undertake behavior
therapy. However for the maintenance of treatment gains, in vivo exposure has to be added in the latter
part of the treatment.
Response Prevention, based on the extinction model, is used as an adjuvant strategy to exposure in
behavior therapy. Following exposure, patients are prevented from engaging in rituals that initially caused
increases in obsessions and anxiety, thereby allowing them to remain in their feared situations. Typically,
response prevention leads to a gradual reduction in anxiety and obsessions. Prolonged exposure to the
feared situations and response prevention or avoidance of rituals leads to habituation.
Modelling- this involves the therapist carrying out the required task before the patient does so;
compliance is increased if the therapist is exposed to the feared stimuli more than the patient is asked to.
In addition to better compliance, it is one of the clearest ways of demonstrating which behaviors are
required or not required during exposure and response prevention. However, modeling should be rapidly
faded out once treatment has started because it can serve as a powerful form of reassurance.
Steps for ERP
Before beginning therapy, it is important to educate the patient about the symptoms, causes and treatment
of OCD. In addition, it is also essential that baseline assessment (such as use of rating scales) is done to
monitor the progress in therapy.
Step I: Explaining the rationale for using exposure response prevention – the anxiety relieving ability that
the rituals possess is very short lived and over a period of time, it tends to increase ritualizing behavior. It
is explained to the patient that an obsession initially leads to a significant rise in anxiety, discomfort and
urge to ritualize. However, this rise remains quite steady and then gradually decreases such that after
sometime, the discomfort almost returns to normal even without engaging in the ritual. When the
individual is exposed repeatedly, the initial discomfort and anxiety is less with each exposure and time
taken to return to normal is also shortened.
Engaging in a ritual brings about Repeated exposure reduces the initial

an immediate and dramatic anxiety level as well as the time it takes for
decrease in both these the anxiety to return to normal
measures.
Step II: Explain the subjective unit of distress scale (SUDS) which is a self rating system designed to
measure the amount of anxiety the person feels. It is a 100 point scale with 100 equaling the most anxiety
provoking situation and 0 equals no or neutral anxiety. A 50 is neither high nor low. It indicates just
medium anxiety.
Step III: Writing an exposure list which should include 10 to 15 specific situations that trigger different
levels of anxiety. The situations or triggers should differ from each other by about 5 – 10 SUDS. The list
should begin with SUDS of the lowest level (20 – 30) and the highest being 100. From the master list, one
or more than one mini lists can be made.
Step IV: A mini list is chosen and the individual starts with items that provoke at least a moderate amount
of anxiety. With each item, the individual is expected to allow the discomfort to be, and stay with it rather
than avoiding it. Exposure to a particular item goes on till the SUDS level reaches 20 – 30. This process is
repeated for all the items on the list. (Hyman & Pedrick, 1999)
Habituation Training- The practical task in habituation training is repeatedly and predictably to elicit
thoughts over the period required for anxiety reduction, while at the same time preventing any covert
avoidance and neutralizing behavior. Intrusive thoughts are frequently experienced with the
accompanying emotions of fear and dread as well as physiological responses such as a racing heart,
sweaty palms, dry mouth etc. The process of desensitizing oneself to such thoughts involves deliberately
exposing to these thoughts until the thoughts occur without the accompanying discomfort. (Hyman &
Pedrick, 1999)
 Written Exposure – where the individual is required to write the intrusive thoughts down and
resist avoiding, distracting, or ritualizing away the anxiety of the thought. The individual is
expected to rate his subjective unit of distress before starting and continue writing until his SUDS
level reaches 20-30.
 Taped Exposure – using a cassette tape recorder, record the thoughts by saying it over and over
till the SUDS level reaches 20 -30. Till then, the individual is expected to rewind the tape and
listen to the thought repeated over and over again.
ERP for common OCD problems (Hyman & Pedrick, 1999)
Washers
Certain rules are developed for normal washing for the purpose of ERP (Hyman & Pedrick, 1999) such as
one hand wash for less than 30 seconds before and after meals, after toileting, after touching a greasy or
visibly dirty thing; One shower per day (7 minutes for men and 10 minutes for women with no rituals
during shower etc.
Fast track method Gradual Method (Ritual delay)
For a period of three weeks, the patient is advised This is done in three phases:
severe limits in the use of water. Clear rules are o Phase I – patient works on becoming
formulated for the time utilized for each activity comfortable with the idea of delaying
such as not more than 7 minutes for taking a bath, washing, while at the same time actually
restrict hand washing to a maximum of 6 times in a shortening the duration of washing.
day. It is restricted to certain times of the day such o Phase II – the patient will be permitted to
as before and after having meals, after using the wash hands only after their SUDS has gone
washroom, or handling dirty things etc. in addition, down. Also, the patient will continue to reduce
they are advised to use as little water as possible or the length of the time and the number of times
even avoid using water wherever possible. Once he or she washes during the day.
progress is made, normal hand washing can be o Phase III – Patient is exposed to increasingly
started. anxiety provoking situations and reduce
washing to normal levels.
Checkers
When doing exposure and ritual prevention for checking, work towards the goal of checking only once in
situations when most people might do so. For example, doors, locks, faucets, appliances etc. should be
checked only once before leaving the house or going to the bed. Strict ritual prevention for checking is
very challenging. The following techniques help in dealing with the powerful urges to check:
 Use Procrastination as a part of ritual prevention. Patients are encouraged to make a deal with
themselves to check it later. Often by the time ―later‖ comes, the urge to check will have passed.
 Use of Distraction techniques to avoid checking.
 Use of Overcorrection – for example plan to check once every five minutes for a period of one
hour. This makes checking more cumbersome and thus may inhibit it.
 Use of self talk techniques and correcting faulty beliefs
Ordering and Symmetry

Exposure and ritual prevention consists of gradual habituation to the purposeful placement of objects in
the ―wrong‖ imperfect places. Ritual prevention involves the management of the compulsive urge to
restore these objects to previous ―perfect‖ positions. Exposure to the items is done in a manner such that
one proceeds from the least anxiety provoking to the most anxiety provoking.
Obsessional Slowness
People with obsessional slowness may benefit with procedures involving monitoring the length of time it
takes to do various tasks. First, it is important to decide on a goal for the length of time it should take to
complete various activities of daily living, such as dressing, showering etc. Then, the patient is
encouraged to pace oneself in such a way that he or she makes a goal of decreasing that time to complete
the task by two to five minutes per day. A simple watch or a countdown alarm timer is used or a friend or
family member can help.
Hoarding
According to Frost and Steketee (1998), the following five features characterize persons with hoarding
OCD:
a. Indecisiveness – Inability to take a satisfactory decision appears to be related to the fear of
making mistakes. Hoarding useless objects may thus be a means of avoiding making bad
decisions or a decision that may be regretted later.
b. Categorization Problems – People with hoarding OCD have difficulty sorting objects into useful
classifications for efficient use or discard. One object seems as important and vital as another.
c. Beliefs about memory – despite little evidence of their having memory problems, people with
hoarding OCD fear that their faulty memory will prevent them from having access to all their
possessions. This lack of confidence in their own memory renders the compulsive hoarder
reluctant to put items away and out of sight.
d. Excessive emotional attachment to things – they attach much more sentiment to objects and find
an extreme degree of emotional comfort in their possessions.
e. Control of Ownership – People with Hoarding OCD have an exaggerated need to feel in control
of their possessions, to protect the items from harm or irresponsible use. Hence they feel extreme
discomfort when the objects are touched or moved by anyone other than them.
Steps involved in the management of the problem are as follows:
I. Assessment of the hoarding problem

 How much of the house is cluttered? Which rooms?
 How much discomfort does it cause to the patient or family members?
 What type of items are saved and why?
 Does the individual organize things at home and what are the strategies used in doing
so.
II. Development of an organization plan for home – Make a list of all the areas in the individual‘s
home and how much space is being used in each of these areas. Also, the individual is asked to
assess approximately what percent of the usable space is currently cluttered and what would be
the goal for the functional use of the space.
III. Decide where to start first – choose an area that is small and is least cluttered. Another way to
start is to pick up an item that one has many in a small area such as books, clothing or papers and
work only on that class of item first. Since it is easier to store large groups of similar objects, the
job will be faster and provide faster satisfaction.
IV. Establish a few easy rules for placing, storing and discarding objects and stick to them – Place
three empty boxes in the area to be worked on. Label one box ― store‖, the next box ―sell‖ or
―donate‖ and the third box ―Discard‖. One helpful rule for uncluttering (Frost and Steketee, 1998)
is called the OHIO rule: Only handle it once. This means that once an item is touched or picked
up, it cannot be returned to the clutter pile. It must be kept in one of the three boxes. It is also
helpful to set rules for putting items in each of those boxes. For example, if the individual does
not foresee a specific use of an object in the next six months, put it in the ―discard‖ box.
V. When an area is clear, decide how the cleared space can be utilized appropriately – Set about
preparing the area for the intended use and hence utilize that area only for that particular thing.
Establish a ―no clutter‖ rule for a specific space the individual might feel tempted to clutter and
stick to it.
Religious Obsessions
Exposure and ritual prevention exercises with such individuals generate within them feelings that they are
morally, ethically and spiritually wrong or they are doing damage to their spiritual identity. To help deal
with these issues, it is advisable to choose a trusted, prudent person who will serve as a spiritual advisor
or a moral/ethical guide who will help the patient deal with the changes he or she will be going through.
The person however should have adequate knowledge about religious OCD.
Thought Stopping
It aims to provide a strategy for dismissing thoughts and thereby reducing their duration. This may have a
sense of increasing the patient‘s sense of self control and hence reduce discomfort. The patient is
generally encouraged to sit in a relaxed manner with eyes closed. The therapist describes a scene of the
patient getting an obsessional thought and the patient is encouraged to raise a hand as soon as he/she
begins thinking about that thought. As soon as the patient raises a hand, the therapist shouts ―stop‖ and
then asks the patient to switch to an alternative scene. The patient is encouraged to think in detail of this
scene and raise a hand when there is a clear thought or picture in his or her mind. The therapist then asks
the patient to rate the discomfort and vividness associated with the obsessional thought and also checks
whether the person was able to imagine the alternative scene in detail. This is done a variety of triggering
scenes and alternative thoughts. Next, the procedure is altered so that the therapist describes the scene and
the patient says ―stop‖ and describes the alternate scene. In the third phase of this procedure, the patient is
encouraged to think of the alternate scene without verbalizing it. For example, a 33 year old homemaker
was having intrusive thoughts that she might deliberately harm her children. To deal with this anxiety
provoking thought, she would engage in covert rituals such as ―I really don‘t want to do that‖. She was
encouraged to shout stop in response to the intrusive thought and imagine a pleasant scene as vividly and
clearly as possible. Importantly, it should be kept in mind that the alternative scene should not have any
neutralizing thought or image.
Thought stopping is practiced with the patient in the subsequent sessions, emphasizing the importance of
not neutralizing. Homework consists of approximately 20 minutes practice each day at times when the
patient is not distressed by the thoughts. A diary of practice is kept with ratings from 0 – 100 made of the
distress and vividness associated with each evocation of the obsessional thoughts. A variation of this
technique called the rubber band technique is also used. The individual is asked to tweak a rubber-band
which is around their wrist whenever they have an intrusive thought as a means of stopping it. (Hawton et
al., 2000).
Cognitive therapy (CT)

Drawing on a growing body of clinical and empirical literature on cognitive distortions in OCD, the
Obsessive Compulsive Cognitions Working Group (OCCWG, 1997) outlined three cognitive levels of
analysis in need of study in OCD:(1) intrusions, that is, unwanted thoughts, impulses, or images; (2)
appraisals, that is, meaning given to a specific event such as an intrusion; and (3) beliefs, that is, relatively
enduring assumptions often held by OCD patients. Moreover, based on empirical research and expert
consensus, the OCCWG outlined six domains of beliefs thought to be relevant in the development and
maintenance of OCD. A brief description of each domain follows.
Category Description
Excessive Belief that one has power to cause or the duty to prevent negative outcomes
responsibility featured in intrusive thoughts.
Overimportance of Belief that the mere presence of a thought indicates that the thought is significant.
Thoughts
Need to control Belief that complete control over one‘s thoughts is both necessary and possible.
thoughts
Over estimation of Belief that negative events associated with intrusive thoughts are likely and would
threat be insufferable.
Perfectionism Belief that mistakes and imperfection are intolerable.
Intolerance for Belief that it is necessary and possible to be 100% certain that negative outcomes
uncertainty will not occur.
TECHNIQUES USED IN COGNITIVE THERAPY FOR OCD

Some examples of CT techniques found especially effective are briefly described below. General
techniques are listed first, followed by OCD-belief domain-specific techniques. (Abramowitz & Houts,
2005).
General Techniques
Explaining the Cognitive Model: Therapists explain that psychological distress (eg, anxiety, guilt) does
not result from intrusive thoughts or certain situations per se, but rather from how the individual appraises
and responds to such stimuli (Beck, 1976). Patients learn how dysfunctional appraisals and beliefs lead to
negative emotional responses, and to behavioral patterns, (eg, compulsions, avoidance) intended to
neutralize anxiety or guilt. Finally, patients learn about the role of rituals and avoidance in the
maintenance of OCD (eg, Salkovskis, 1985).
Socratic Questioning: Using Socratic dialogue, therapists assist patients to systematically examine the
logic that underlies their mistaken beliefs. Therapists offer logical corollaries to patients‘ flawed logic,
play devil‘s advocate, and ask questions such as: ―ये विचार आपके लऱए ककतने फयदे मंद है ?‖; ―क्या प्रमाण है जो
इस विचार के साथ जाता है ?‖; ―क्या प्रमाण है जो इस विचार के साथ नही जाता है ?‖
Downward Arrow Technique: Therapists repetitively (but gently) query patients about the meaning they
ascribe to their own intrusive thoughts (eg, ―ये विचार या तस्िीर क्या बताती है ?‖), increasing patients‘ awareness
of their distorted appraisals of unwanted thoughts. Further questioning (eg, ―और इसका क्या मत्ऱब है ?‖) helps
OCD patients identify dysfunctional beliefs associated with intrusions and appraisals (eg, Wilhelm, 2001,
2003).
Identification of Cognitive Errors: Patients are shown a list of common cognitive errors (eg:
catastrophizing – always expecting the worst outcome without any proper evidence), asked to identify
which errors they engage in when interpreting stimuli and situations, and helped to generate alternative
interpretations.
OCD Belief Domain-Specific Techniques

The techniques listed below are described in detail in multiple CT protocols . They are grouped according
to belief domains in which they are frequently used but can often be used in other beliefs domains.
Techniques for Reducing Exaggerated Estimates of Responsibility
Courtroom Role Play: Patients and therapist engage in a role play in which patients act as prosecuting
attorneys and therapists act as judges or defense attorneys. Patients present arguments in an attempt to
prove their own guilt for causing a feared consequence. Therapists present arguments demonstrating that
the patients‘ ―evidence‖ (eg, they feel guilty—without any evidence of wrongdoing) would never hold up
in court. This helps illustrate to patients how they overestimate their personal responsibility for the feared
consequences.
Pie Technique: Patients identify a feared consequence (eg, ―I rolled the window of my car &
unknowingly a paper blew out of the window onto the windshield of another driver‘s car and an accident
will occur‖) and give an initial estimate of the percent responsibility that would be attributable to them if
this consequence were to occur. Patients then generate a list of the other causes (other than themselves)
that would have some responsibility for the feared consequence (eg, careless driving, poor road
conditions, poor driving skills, driver emotionally upset, driver drunk etc). They then draw a pie chart,
each slice of which represents one of the responsible parties identified. Next, patients label all causes‘
slices according to their percent responsibility (eg, poor skill driving—50% responsibility, poor road
conditions—25%, etc) and label their own slice last. By the exercise‘s end, it is generally clear to patients
that the majority of the responsibility for the feared event would not be their own.
Techniques for Reducing the Over importance of Thoughts
Psycho-education to Normalize Intrusions: To help patients view their experiences with unpleasant
intrusive thoughts as normal and universal, therapists can give patients a list of intrusive thoughts
reported by individuals who do not have OCD (eg,Wilhelm & Steketee, 2002). This enables patients to
see how their own intrusive thoughts (eg, thoughts of harming loved ones) are similar in content to those
reported by others without OCD. Patients often report feeling relieved when they realize that intrusions
are experienced universally and not an indication of depravity or ―craziness.‖ Furthermore, the realization
that most people experience these intrusions without associated anxiety can underscore the importance of
therapeutically addressing beliefs and interpretations about intrusions rather than trying to eliminate the
intrusions per se.
Cognitive Continuum: This technique assists patients to discriminate between the presence of an
intrusion and the commission of a negative act. As such, it can be especially effective in modifying Moral
TAF. Using a visual analog scale from 0 (most moral person ever) to 100 (most immoral person ever),
patients rate how immoral they are for having intrusive thoughts. Next, patients rate the morality level of
other individuals who have committed acts of varying degrees of immorality (eg, a serial rapist, abusive
parents). Then, patients re-rate themselves and reevaluate how immoral they are for simply experiencing
intrusive thoughts.
Behavioral Experiments: Patients conduct ―experiments‖ to evaluate the accuracy of their predictions
regarding obsessional fears. Behavioral experiments in CT are usually brief, and used only to test
patients‘ maladaptive predictions against other, more rational predictions. For example, a patient who
believes that thinking about a negative event will lead to committing the corresponding action might be
given a fragile object to hold and instructed to think about purposely breaking the object. Next, the
therapist would review with the patient whether the original hypothesis (eg, my thoughts will make me
break the object) was supported (eg, ―Is the object still intact?‖ ―Was there any attempt to break it?‖).
Ultimately, patients come to realize that merely thinking about something does not lead to the occurrence
of the corresponding event.
Techniques for Reducing the Need to Control Thoughts
Thought Suppression Test: Patients are instructed to think of an animal (eg, a giraffe) as frequently as
they can; and record the number of times they experience a thought about the animal within a given time
frame (eg, 1 min). Next, they are instructed not to think about the animal for 1 min, but to record the
number of times the thought intrusively comes to mind. In most cases, patients report a greater number of
animal thoughts while trying to suppress compared to when, trying to generate such thoughts. This
demonstrates how attempting to suppress distressing obsessional thoughts (an oft-utilized strategy for
OCD patients) is counterproductive.
Techniques for Reducing Overestimates of Danger
Calculating Probability Estimates: First, patients are asked to provide an estimate of the probability that a
feared consequence (eg, leaving a lamp on and burning the house down) will occur. Next, patients make a
list of the chain of individual events that would need to occur in order for their feared consequence to
occur (eg, lamp over-heats, lamp shade comes in contact with light bulb, etc). Then, patients estimate the
probability of the occurrence of each individual event listed in the chain. Then, using a calculator,
patients calculate the cumulative probability of the ultimate, feared consequence (ie, the house burning
down) by multiplying the probabilities of each individual event in the chain. Finally, patients compare
their previously estimated ―gut level‖ probability with the mathematically derived cumulative probability
(which is usually a great deal lower), demonstrating how dramatically they overestimate the likelihood of
danger.
Techniques for Reducing the Intolerance of Uncertainty
The ―Advantages and Disadvantages‖ Technique: Once patients identify the various distorted beliefs that
underlie their fears of intrusive thoughts, they make a list of the advantages and the disadvantages of
maintaining what they now recognize as distorted beliefs. This exercise can help point out how the
advantages of being certain about a few things are usually far outweighed by the disadvantages of
maintaining distorted, uncertainty-related beliefs that perpetuate significant anxiety and impairment.
Techniques for Reducing Perfectionistic Beliefs
Perspective Taking: Patients are asked whether they expect others (eg, their children, friends, etc) to be
perfect, and whether they have contempt for those who make minor mistakes (eg, in a letter or a
homework assignment). This is usually followed by a discussion about why patients believe it is OK for
others, but not themselves, to make such mistakes.
Advantages and Disadvantages: As described above, this technique may also be effective in modifying
beliefs about the importance of being perfect. By listing the advantages and disadvantages of trying to
attain perfection, patients often come to realize that the drawbacks of their perfectionism (eg, loss of time,
procrastination, loss of enjoyment, academic or occupational impairment) far outweigh the benefits of
trying to make things perfect.
Newer trends in Cognitive Behavior Therapy
Cognitive Bio-behavioral Self Treatment (Schwartz, 1996)

Behavioral self treatment for OCD is becoming increasingly recognized as an effective and efficient
method of clinical management (Munford et al., 1994). The OCD research group at UCLA Medical
Center has been utilizing a cognitive behavioral self treatment technique over the past several years
(Schwartz, 1996). They provide scientific evidence that cognitive therapy alone can cause chemical
changes in the brains of people with OCD. They suggest four steps, the end result of which is enhanced
self control and enhanced self command resulting in heightened self esteem. These four steps are as
follows:
Relabel: it is of the utmost importance that the OCD patient work to consciously increase his or her
mindful awareness that the bothersome intrusive thoughts and urges are obsessive thoughts and
compulsive urges i.e. symptoms of a psychiatric disorder. Mental notes are made to enhance this
recognition as it is happening eg. ―I don‘t think that my hands and feet are dirty rather I am just having
the obsession that my hands are dirty.‖ While this certainly will not make the urge go away, it begins the
critical process of not taking OCD thoughts and urges at face value. The question then arises why this
thought is bothering me which leads to the next step – reattribute.
Reattribute: structured education about the medical basis of OCD is a foundation on which one helps the
patient to build a working knowledge about why the OCD thoughts and urges are so intrusive, persistent
and bothersome. This improves the patient‘s ability to not take the OCD thoughts at face value, to view
them as ―false messages‖ that are due to chemical changes in the brain. Patients are provided with PET
scan pictures of brains of OCD patients before and after doing cognitive behavioral treatments as a
material aid to this cognitive reattribution step. Many patients find this motivational as well as a reminder
not to take the urge or thought at face value.
Refocus: it involves actively engaging in almost any reasonable activity or task rather than doing
compulsions or becoming fixated on obsessive thoughts. It can be any activity such as physical activity,
listening to music, knitting, playing a computer game; but it must be something that the person enjoys
doing. The important thing is that for at least a few minutes, the patient will not be sitting and dwelling
self destructively on the bothersome thoughts and urges that have invaded his or her mind and he or she
will not be acting on those thoughts and urges. Instead, patient is encouraged to relabel those thoughts as
OCD and senseless, reattributing it to the chemical changes in the brain and refocusing on another
activity, training oneself to bring focus away from OCD to reality.
Revalue: practicing self directed response prevention for enough time to allow full habituation is, of
course, the ultimate treatment goal. After being trained in the first three steps, the patient begins to place a
different, much lower, value on the thoughts and feelings that arise due to OCD. One reasonable way to
conceptualize this is that self treatment leads to brain changes, which leads to diminished symptom
intensity, which enhances a process of revaluation of the symptoms, which enhances continued
application of the relabel, reattribute, and refocus steps, leading to further brain changes and so on. A
therapeutic, self enabling, feed forward process is established.
Metacognitive Therapy (MCT) (Wells, 2009)

Two basic types of metacognitive change are the focus of MCT. These are (1) how the patient relates to
and experiences thoughts (e.g., nature of experiential awareness), and (2) what the individual believes
about thoughts. MCT focuses on developing an alternative way of experiencing thoughts and modifies
beliefs about the meaning and importance of thoughts and feelings. Treatment also focuses on modifying
beliefs about rituals and the inappropriate internal criteria and strategies individuals with OCD appear to
use to determine the level of threat in situations. An important early task in treatment is shifting the
patient from an object mode to a metacognitive mode of processing. In other words, the patient has to be
taught to consciously see the thoughts as separate from the self. There are four components in OCD
treatment (Wells, 2009):
Awareness: Initially, the therapist helps the patient to identify instances of obsessional thoughts. To
increase awareness the therapist reviews several recent episodes of neutralizing and distress and examines
the specific intrusions that occurred. The therapist helps the patient to identify this thought or feeling as a
trigger to which detached mindfulness should be applied. The patient is instructed to be aware of this
trigger in the future.
Detached Mindfulness (DM): Strategies for achieving DM are then implemented. This is first practiced
with a neutral thought and then with an obsessional thought. This step is followed by intensifying the
experience of DM by attempting greater awareness of separation between the sense of self and the
intrusive thought. (Details given in Appendix 5)
Exposure and Response Commission: The therapist suggests that instead of getting rid of thoughts, one
way to obtain distance from them and discover that they are unimportant events in the mind is to continue
with rituals but to maintain the intrusion throughout. This technique is called exposure and response
commission (ERC). For example, a patient with contamination fears would wash and dry his hands
repeatedly until he was able to wash and dry without having thoughts about contamination. He was asked
to repeat continuously and covertly the thought ―I‘m contaminated with bacteria‖ for the duration of any
washing. This activity facilitates detachment from the thought and strengthening of meta-level
experiencing of the intrusion.
Metacognitively Delivered Exposure and Ritual Prevention: ERP is also used in MCT but is presented
in two ways: as a means of reducing the patient‘s overestimation of threat and as a behavioral experiment
to challenge metacognitive beliefs in the domains of TEF, TAF, and TOF. When ERP is used as a
behavioral experiment the patient is asked to make a prediction based on metacognitive beliefs about
thoughts and to test this prediction by having obsessional thoughts and refraining from enacting
neutralizing responses. For example, a patient was concerned about having thoughts of killing her
daughter because she believed that these thoughts would make her kill her daughter (TAF). To prevent
this, she would normally respond to these thoughts by imagining playing with her daughter, hugging and
kissing her and trying to hold onto a clear image of both of them happy. The therapist worked with the
patient to operationalize an experiment where, in response to such thoughts, does she actually engage in
the action.
Acceptance and Commitment Therapy (Harris, 2006)

The more time and energy one spends trying to get rid of unwanted private experiences the more they are
likely to suffer psychologically in the long term. A large body of research shows that higher experiential
avoidance is associated with anxiety disorders, the most florid of which is OCD. In ACT, there is no
attempt to try to reduce, change, avoid or suppress these private experiences. Instead, clients learn to
reduce the impact and influence of unwanted thoughts and feelings, through the effective use of
mindfulness. Thus, ACT focuses around two main processes: 1) developing acceptance of unwanted
private experiences which are out of personal control; 2) commitment and action toward living a valued
life. Following are 6 core principles of ACT (Harris, 2006):
 Defusion: In a state of cognitive fusion, one‘s thoughts seem to be literal truth, or rules that must be
obeyed or threatening events that must be gotten rid of and thus they seem to have an enormous effect
on one‘s behavior. In cognitive defusion, one is taught to step back and observe language, without
being caught up in it. One learns to recognize that their thoughts are nothing more or less than
transient private events – an ever changing stream of words, sounds and pictures. As one defuses these
thoughts, they have much less impact and influence.
 Acceptance: Making room for unpleasant feelings, sensations, urges and other private experiences;
allowing them to come and go without struggling with them, running from them or giving them undue
attention.
 Contact with the present moment: Bringing full awareness to one‘s here and now experience with
openness, interest and receptiveness, focusing on and engaging fully in what he or she is doing. While
one is doing this, all sorts of distracting thoughts and feelings may arise. The aim is simply to let the
thoughts come and go and allow the feeling to be in there and keep all the attention focused on the
work at hand. Homework includes practicing full engagement with all five senses in a number of daily
routines (having a shower, brushing teeth, eating, and cleaning room).
 The observing self: It is possible to experience directly that one is not their thoughts, feelings, urges
and images. These phenomena change constantly and are peripheral aspects of an individual, but they
are not the essence of who he or she is. There are two processes – a process of thinking and a process
of observing that thinking. Thus, there arises a difference between the thoughts and the self who
observes these thoughts. From the perspective of this Observing self, no thought is dangerous,
threatening, or controlling.
 Values & Committed Action: Clarifying what is most important to oneself, what one wants to
become and what is significant and meaningful to oneself and setting goals guided by one‘s values and
taking effective actions to achieve them.
Danger Ideation Reduction Therapy (Herson & Sledge, 2002)

DIRT is a cognitive-behavioral treatment package for OCD sufferers who experience contamination
obsessions and washing compulsions. It was developed by Mairwen K. Jones and Ross G. Menzies in the
mid-1990s. It solely aims to decrease danger-related expectancies concerning contamination and disease.
A core tenet of DIRT is that clients perform compulsive washing behaviors in response to faulty beliefs
about contaminants in the environment and the ease with which contact with ―contaminated‖ stimuli will
lead to illness. Each component of DIRT aims to decrease the patient‘s belief in the likelihood of
dangerous outcomes with respect to contamination (Herson & Sledge, 2002).
Cognitive The therapist encourages the patient to identify unrealistic thoughts related to
Restructuring contamination/illness and teaches the patient to reevaluate these thoughts, changing
them to be more realistic and appropriate to the demands of the situation. Once
constructed, participants are asked to rote learn their reappraisals, reading and copying
them on a daily basis. In later sessions, participants are shown how to apply their
reappraisals to novel situations.
Filmed This component involves the presentation of filmed interviews with workers employed
Interviews in a range of occupations which involve regular contact with contamination related
stimuli such as house cleaning, gardening, banking, nurse etc. Each interviewee
describes in detail the frequent contact with OCD-related stimuli (e.g., chemicals,
garden soil, animal hair, bodily fluids, money). Interviewees are then asked about their
health and level of sick leave over the course of their employment. The therapist
highlights the absence of work-related illnesses in each interviewed employee.
Corrective The information provided to clients highlights common misconceptions about illness
Information and disease and the ease with which a variety of conditions can be contracted.
Additional information is provided to participants concerning the problems inherent
with excessive hand washing. This includes a one-page microbiological report that
explains how vigorous washing can damage the integrity of the skin, causing cracks
and fissures that break down the protective barrier to infection.
Microbiological The experiments involved the researchers ―contaminating‖ one hand by touching a
Experiments number of stimuli commonly found to be anxiety provoking to OCD washers,
(including garbage bins, toilet doors, and animal hair), while the other hand acted as a
control. Fingerprints from both hands were imprinted on sheep blood agar plates.
Following the description of the experiments the therapist directs the patient to the
research report findings which state that no disease-causing organisms were isolated
from fingerprints on the sheep blood agar plates following contact with OCD-relevant
stimuli. Discussion of the results focuses on challenging patient‘s previous excessive
risk estimates associated with these tasks.
The probability This procedure involves comparing patient estimates of the probability of a negative
of catastrophe outcome with an estimate derived from an analysis of the sequence of events that might
lead to the feared outcome. Behaviors, such as throwing out the garbage, are broken
down into the sequence of events required for contamination or illness to occur (e.g.,
bacteria present on garbage bin, bacterial transfer to hand, bacteria entering the body,
initial immune system failure). Probability estimates for each step in the sequence are
given by the participant. These are multiplied together to give a new estimate of the
likelihood of illness. The therapist highlights the inconsistency between the patient‘s
initial elevated global estimates and those lower probability estimates obtained using
the probability sequencing task. Homework consists of applying this method to novel
situations.
Attention It involves a focusing task that aims to decrease the occurrence of danger-related
Focusing intrusive thoughts by increasing the participant‘s ability to attend to alternative
cognitive targets in a rhythmic breathing exercise. Participants are taught to focus on a
series of numbers while breathing in and to focus on the word ―relax‖ while breathing
out. Participants are instructed to breathe normally and not to slow or speed up the
respiration rate. Participants initially train themselves with their eyes closed in a quiet
location with minimal noise and distraction. As training progresses across sessions,
participants are instructed to increasingly complete their daily focusing sessions in
noisier environments while keeping their eyes open. Daily practice consists of two, 10-
min focusing sessions.
Other Modes of Treatment
Psychodynamic Therapy
Psychodynamic treatment, particularly psychoanalytic treatment of obsessive compulsive conditions has a
long history, beginning with Freud. Psychodynamic therapy, especially in its early days and probably to a
certain extent still, relied for its effectiveness on interpretations concerning the presumed origins of
symptoms in early personal history that produced little or no therapeutic change. In more recent years,
however, psychodynamic therapy has undergone important developments; historical interpretations of the
traditional sort are no longer relied as the exclusive therapeutic goal of understanding the origin of
symptoms; understanding the patient in the ―here and now‖ and in the therapeutic relationship itself is
emphasized. The occupation with ineffective historical speculation is therefore much diminished in
contemporary psychodynamic therapy. There is, in addition, a particular current in psychodynamic theory
and therapy that is critical in the treatment of obsessive-compulsive conditions, namely the development
of a characterological viewpoint. A great deal of clinical evidence indicates that obsessive compulsive
symptoms are special expressions of a certain sort of neurotic character or personality (Shapiro, 1965).
Starting in the late 1920s and the early 1930s, especially with the introduction of character analysis by
Wilhelm Reich (Shapiro, 1965), the ―intellectualization‖ and general rigidity of obsessive individuals
have been recognized as central to the dynamics of the character, as well as symptoms. With the
recognition and the further development of characterological psychodynamic treatment in more recent
years (Fierman, 1965; Shapiro, 1989), the reasons for considering obsessive compulsive conditions
particularly intractable have disappeared and successful treatment has been reported (Fierman, 1965;
Shapiro, 1989)
GROUP THERAPY IN OCD

Group behavioral treatments have proven effective for several anxiety disorder patient populations, and a
handful of studies have investigated group treatments for OCD. A supportive treatment group will
provide a motivational boost for those sufferers who feel they can‘t carry out the homework without the
accountability of the group and compassion of other OCD patients. Yalom identified ―curative factors‖
common in groups, some of which are present and act as powerful forces in behavioral treatment groups
of OCD patients: instillation of hope, imitative behavior, imparting of information, universality,
development of socializing techniques, group cohesiveness, catharsis and altruism.
Hollander (1997) found the following advantages of group therapy:
o Group cohesion and trust among the members paves the way for using ERP and modeling in the
group. In addition, the heterogeneity of symptoms tend to promote insight into OCD facilitating
greater participation in exposure.
o In addition, praise and appreciation as well as feedback from other members enhances their
motivation and makes the task appear more achievable.
o Imparting information and learning from other patients appeared to be beneficial because patients
respected the advice that came from someone ―in the same boat‖.
MANAGING CHILDREN WITH OCD

Children as young as five may benefit from Cognitive behavior therapy as well as Exposure Response
Prevention, given adaptations to content and presentation. While the general structure of the treatment
follows that for older children, adaptations include simpler language, a greater use of stories, metaphors,
role plays and humor, more extensive education and a need to ensure that the family‘s beliefs are
acknowledged and managed. Family plays a crucial role in the management as well as the maintenance of
therapeutic gains (Hyman & Pedrick, 1999).
A. Thinking of OCD as a bully – the aim of the first treatment session is to introduce the cognitive model
of OCD. With younger children, a simple way is to compare OCD to a bully. Most children know that
bullies are mean, scare people and try to make them do things that they don‘t want to do. OCD is also
similar as it is mean, scary and makes children do what they don‘t want to (rituals). These concepts
can be illustrated with the help of simple role plays where the therapist plays the role of a bully and
demands his tiffin from the child. If the child gives it, he or she is encouraged to think about what the
bully will do on subsequent situations and whether the child should stand up or ignore the bully. Once
the child understands how a bully works, it can be compared to OCD and conceptualized in a better
manner.
B. The itchy bite metaphor – As part of the preparation for behavior change, the therapist attempts to
loosen the child‘s beliefs in the usefulness of rituals and other unhelpful strategies by discussing
whether the child‘s solutions might be making it worse or better. The therapist compares OCD to a
mosquito bite. When we scratch it, one feels relieved, but for a short period of time and the area
becomes bigger, redder and itchier thus pointing out that scratching it makes it worse. The therapist
then suggests that the rituals might be similar to scratching and could ask the child if the rituals are
making the problem better or worse.
C. Understanding that thoughts are not enough to cause harm – these are also done through various
examples and behavioral experiments. In addition, the patient is asked to enumerate all those things in
detail that are required to happen in order for the thought or urge to happen. For example, if a child
gets a thought that she might hit her mother, this might not lead to the action. This is because a
sequence of steps are required to hit the mother; such as stand up, walk closer to the mother, make
sure no one is looking, raise your hand and so on.
D. Treating thoughts as rude guest who visits house without being asked and says a lot of annoying
things. The child has three options in dealing with the rude guest. They could argue with the guest,
push the guest out or leave the guest alone until they become bored and leave. The child is
subsequently asked to think of the best way to deal with these intrusive thoughts that come to their
mind without being invited.
E. Introducing an alternative explanation to these intrusive thoughts – A simple way is to ask the child to
become a detective to find out whether OCD is telling the truth or is a liar. Both explanations are
written on a piece of paper and the child is asked to rate the child‘s belief in OCD and building
motivation to carry out behavioral experiments. Usually children will co-operate if they are done
swiftly using humor and enthusiasm to reduce anxiety and prevent refusal.
F. Exposure Response Prevention – child will be explained the concept of Subjective Unit of distress
with the help of a feeling thermometer. In the initial sessions of exposure, parents or therapists can
model the appropriate behavior and will also need to give verbal prompts. Each successful session is
reinforced using encouragement, sticker chart and other specific rewards.
OCD AND FAMILY MANAGEMENT

The family plays an important role in OCD treatment and recovery. Family stress and dysfunction, while
not a direct cause of OCD, can powerfully affect the person with OCD and the severity of symptoms
(March & Mulle, 1998). Similarly, OCD in the family can contribute to disruption, discord, and serious
misunderstandings (Yaryuras-Tobias & Neziroglu, 1997). Fighting it and managing OCD, therefore must
be a team effort.
a. Psycho-education to family members and Encourage compliance to medications and therapy
b. Dealing with the self blame or shame associated with family members having OCD. Often, they
fear that they may be regarded as bad parents or siblings.
c. Encourage them to be aware and not participate in OCD rituals. Examples of behaviors that
reinforce OCD could be providing repeated reassurance thus assisting a person with checking
ritual; or taking bath thrice in a day to avoid the anxiety the OCD person suffers; or offering
endless reiterations of facts and theories to reason the OCD away.
d. Obsessive reassurance seeking is usually a distressing and annoying symptom of OCD with
which family members become entangled. Family members are encouraged to use humor to
disengage themselves from reassurance seeking.
e. Help them set realistic expectations from the person with OCD.
DEALING WITH SELF DEFEATING SAFETY BEHAVIOR

When individuals feel threatened and upset, patients with obsessional problems do as we all do – they
seek safety. Some of the tactics they use are helpful, but much of the so-called safety behavior purchases
brief relief at the cost of sustaining the underlying maladaptive cognitions. The main forms of safety
behavior evoked by obsessions are as follows (Menzies & Silva, 2003):
o Avoidance and Escape behavior – a successful escape from a falsely perceived danger can help to
preserve the false belief in danger. The most effective way to reduce false or exaggerated fears is the
well established method of repeated, graded, gradual, planned exposures to the situation that is
feared and avoided. To maximize the effects, a full discussion of the reason for and the details of
repeated exposures is advisable. In some instances, it is helpful to start with a therapeutic modeling
exercise in which the therapist models the desired behavior before the patient copies it.
o Concealment – it can be extremely embarrassing, humiliating, and even painful for people to reveal
the content of obsessions. In such cases, people find it easier to provide a written description of the
obsession. Some patients feel that disclosure of the obsession weakens their power of control, or can
even invalidate their ‗magical‘ powers of control. In such cases, the patient is encourages to select
trusted people who are sympathetic and psychologically minded, and may even need to practice with
the therapist the type and amount of disclosures that is contemplated. As a safeguard it is best to plan
and practice disclosures to more than a single person.
o Thought Suppression – various behavioral experiments are conducted to show the client that
suppressing or controlling a thought increases it more rather than bringing relief. (Example – animal
experiment)
o Neutralization – neutralization may take the form of attempting to substitute an acceptable thought,
or trying to form a safely reassuring image to cancel out the unacceptable thought, or somehow to
‗put matters right‘. Behavioral experiment can be conducted where they use neutralization as well as
prevention of response to see its effect of the anxiety. This in turn will help the client understand that
neutralization behavior only helps in short term reduction in anxiety.
o Reassurance Seeking – the repeated and often insisting seeking of reassurance about one‘s safety, or
in case of obsessions, the safety of others, is a form of maladaptive compulsive behavior and is
therefore discouraged. Friends and relatives are advised to withhold such reassurance and patients
are authoritatively informed that the reassurance gives short term relief but sustains the obsessions,
and also to be reminded that they already know the reply to their request for reassurance.
MANAGEMENT OF DISORDERS WITHIN THE OBSESSIVE COMPULSIVE SPECTRUM

Over the past few years OC spectrum disorders have emerged as a unique category of related disorders
with overlap in symptom profile, demography, family history, neurobiology, clinical course, treatment
response etc. Phenomenologically, Obsessive Compulsive Spectrum Disorders are characterized by:
 Obsessive thoughts or preoccupations with the body (Body dysmorphic disorder,
depersonalization, anorexia nervosa, hypochondriasis).
 Stereotyped motor or grooming behavior (Tourette‘s syndrome, trichotillomania)
 Driven forms of impulse dyscontrol (pathological gambling, sexual compulsions, borderline
personality disorder
Tics, Tourette and Trichotillomania
Habit Reversal
Habit reversal was developed by Nathan Azrin and Greg Nunn in 1973 as a treatment for nervous habits
and tics. There are four major components to the habit reversal procedures:
Awareness It consists of a number of procedures to teach the client to become aware of every
Training instance of the habit behavior as it occurs or when it is about to occur. The client needs to
be aware of each instance of habit in order to use the competing response contingent on
the habit.
Competing Through competing response training, the therapist instructs the client to identify a
Response behavior engage in this behavior for 1-3 minutes each time the habit occurs or when the
Practice client is about to engage in the behavior. A competing behavior has three characteristics:
1) it is incompatible with the habit; 2) it is something that the client can do easily in any
situation; 3) it is something the client can do that is not noticeable to others. For example,
for hair pulling, nail biting or any other habit involving the hands, the competing
response involves holding the hands down at the side and making a fist or grasping
objects.
Habit Control The therapist attempts to increase the client‘s motivation to get rid of the habit thus
Motivation making it more likely that the client will comply with the treatment procedures. Ways of
doing it can be that the therapist discusses the ways in which the habit is inconvenient or
embarrassing. In addition, the client has to be praised for his or her efforts and success in
controlling the habit.
Generalizing It involves teaching the client how to control the habit in everyday situations. The
Training therapist first has the client practice the competing response until the client is using it
correctly in session and then also uses symbolic rehearsal procedures in which the client
imagines himself or herself successfully using the competing response in those situations.
.
Negative Practice
Negative practice is a technique in which a problem behavior is deliberately repeated, or practiced by a
patient to decrease the response in long term. Negative practice has been used as a response reduction
procedure primarily for habits, such as tics or nail biting or in the treatment of specific types of anxiety.
Dunlap further explained that a patient should voluntarily practice the habit under the conditions of
wanting to eliminate the habit, and then the habit could be modified.
Sexual Deviances
Covert Sensitization
Covert sensitization represents one of the major psychotherapeutic behavioral techniques to be applied to
the remediation of sexual deviances. It is a form of conditioning therapy in which a behavior and its
precipitative events are paired with some aversive stimulus in order to promote avoidance of the
precipitative events and thereby to decrease the undesirable behaviors. The aversive stimulus usually
consists of an anxiety-inducing or nausea-inducing image that may be presented verbally by the therapist
or imagined by the client. The aversive scene is individually created, and is specific to each client‘s
problem behavior. The underlying theory of this treatment approach is probably best thought of as a
combination of classical and operant conditioning processes. The therapist works with a client to develop
an aversive image that will be paired with the precipitative events, and with the image of the deviant
behavior itself, according to a classical conditioning paradigm. Once the client‘s deviant behavior has
been classically conditioned, the client should begin to actively avoid or escape the situations associated
with the deviant behavior. The precipitative events, as well as the behavior itself, should elicit a negative
reaction, and thus be aversive. (Herson & Sledge, 2002)
Orgasmic Reconditioning
Orgasmic Reconditioning, also termed masturbatory reconditioning, was introduced for the treatment of
participants seeking modification of their sexual preference. In early studies they were mainly
homosexual men but in last two decades they have been mainly male sexual offenders. Four forms of
orgasmic reconditioning has been reported in the literature (Herson & Sledge, 2002):
 Thematic Shift – the patient is instructed that when he masturbates, he should use his habitual
―inappropriate‖ or deviant fantasy to produce an erection and to maintain sexual arousal. At the point
of ejaculatory inevitability, he is instructed to switch his fantasy to one of an ―appropriate‖ nature, thus
pairing that fantasy with orgasm. Over time the participant is to introduce the non deviant fantasy
earlier and earlier during masturbation. If following the thematic shift he begins to lose arousal he is to
shift back briefly to the deviant fantasy to regain high arousal and then shift again to the non deviant
fantasy. Ultimately he is expected to always masturbate using appropriate fantasies.
 Fantasy Alternation- it was considered by some researchers that as thematic shift was usually carried
out by the participant without direct supervision he may not maintain the required temporal
relationships between deviant and non-deviant fantasy. They changed the procedure to make it easier
for the participant to follow. Rather than shift the thematic content in each session of masturbation, he
was instructed to use alternate sessions, in one of which he used deviant fantasies exclusively and in
the other, non-deviant fantasies exclusively.
 Directed Masturbation – with this form, the participant was instructed to masturbate exclusively to
non-deviant fantasies and to totally avoid masturbating to deviant themes.
 Satiation - the participant under auditory supervision masturbated continuously beyond ejaculation for
a prolonged period, usually about an hour, while fantasizing aloud every variant he could think of on
his deviant activities. Subsequently it was reported the procedure could also be carried out by the
participant at home, where he recorded his verbalizations, for the therapist to check he was following
the instructions.
Pathological Gambling
Based on the spirit and techniques of motivational enhancement therapy developed by Miller (1983) and
later elaborated by Miller and Rollnick (1991), the goal of the treatment if to encourage behavior change
by helping clients to explore and resolve ambivalence. To understand the client‘s motivation to change, the
reasons that caused him or her to decide to modify his or her gambling are discussed. The decisional
matrix is made to assess the advantages and disadvantages of gambling and help them assess the pros and
cons. In addition, it is important to help the client to understand the chain of events that leads to excessive
gambling, and the importance of high risk situations.
Eating Disorders
Comprehensive treatment for eating disorders generally requires attention to four distinct features of these
disorders (Herson & Sledge, 2002):
1. Biological aspects, particularly nutritional status and the deleterious consequences of semi-starvation
and under-nutrition on the one hand, or serious obesity on the other.
2. Eating disorders related behaviors including restrictive and idiosyncratic patterns, eating binges,
purging, ordinarily by means of vomiting and use of laxatives, and excessive, compulsive exercise.
3. Eating disorders related thoughts, attitudes, and emotions, which may include self distorted
perceptions, overvalued ideas, and disparagement, all related to shape and weight, diminished
cognitive complexity and mood and anxiety symptoms
4. Associated psychopathological interpersonal problems, the frequent comorbid conditions of mood,
anxiety, and sometimes family, interpersonal and social situations accompanying many clinical eating
disorders.
Most Commonly used treatment approach for eating disorders is Cognitive behavior therapy involving
detailed psycho-education regarding the illness, maintaining an eating diary with details regarding food
intake as well as the associated thoughts and feelings. With the help of downward arrow technique and
behavioral experiments, various faulty beliefs are identified that are further modified and various self talk
strategies are taught to the patient.
Body Dysmorphic Disorder (BDD)

The cognitive and behavioral manifestations of BDD resemble, at least superficially those found in other
anxiety disorders such as do the social anxiety and avoidance commonly associated with BDD.
Preliminary studies suggest that exposure and prevention combined with cognitive therapy is effective.
Therapy sessions consist of education about causation and treatment of BDD, constructing a hierarchy of
distressing situations, homework assignments involving exposure to anxiety provoking situations and
preventing body checking behaviors, as well as keeping a body image diary (Hyman & Pedrick, 1999).
Hypochondriasis
The main tenet of the cognitive model of hypochondriasis is that the disorder results from, and is
maintained by, the misinterpretation of normal bodily signs and symptoms as a sign of serious
organic pathology. The main focus of treatment will be cognitive behavior therapy where their
beliefs will be challenged with the help of behavioral experiments and reattribution techniques
will be taught (Wells, 2009).
MAINTAINING TREATMENT GAINS AND MANAGING RELAPSE

Patients should be informed that even in the best scenario, they can expect to experience bumps in the
road with residual OCD symptoms. The patient should be adequately informed about the following
(Hyman & Pedrick, 1999):
1. Identifying High risk situations – Even following successful treatment, most patients report that
certain situations or thoughts occasionally still evoke ritualistic urges. These stimuli can be termed as
high risk situations. If the patient can anticipate high risk situations, he or she will be better prepared.
Times of increased life stress might themselves be high risk situations.
2. Increasing Motivation – Breaking free from OCD is hard work and sometimes patients find their
motivation weakening. Patients are encouraged to make contracts with themselves where they
reinforce themselves if they do not engage in safety or avoidance behaviors. In addition, they are
asked to compose a self motivational narrative highlighting the benefits of reducing OCD symptoms
and how it has changed his or her life.
3. Lapse versus Relapse – Patients should be explained about lapse and relapse and are explained about
abstinence violation effect (AVE). Inevitably, when a ritual is performed, the person berates himself
or herself for violating self imposed, yet unrealistically obtainable standard. At that point, the person
decides that because he or she has already spoiled the plan for complete abstinence, he or she might
as well continue to ritualize. This is called the abstinence violation effect. Patients are asked to
constantly remind themselves that lapse is not a sign of failure, rather an opportunity to refine their
skills.
4. Maintain a healthy lifestyle – A healthy lifestyle helps an individual stick to their program. It includes
staying busy, having a nutritious and a well balanced diet, adequate exercise & reduce stress.
TREATMENT RESISTANT OCD
The concept of ‗resistance‘ was traditionally used in psychoanalytic circles to describe personality
characteristics and attitudes of a client, rather than aspects of the therapeutic process. Behavioral and
cognitive therapists, on the other hand, were more concerned to identify and define problem behaviors
that may arise within the therapeutic context (Sookman & Leahy, 2010).
Clinical Features with difficult clients
1. Lack of motivation for treatment: Motivational problems are often associated with an unwillingness
to face high levels of anxiety, especially when the outcome is perceived as uncertain. Some patients,
especially those who have committed themselves to treatment as a result of external pressures, have
been observed to develop subtle avoidance strategies that can be difficult to detect by an
inexperienced therapist.
2. Lack of Understanding of the treatment rationale: The treatment choice of ERP is not immediately
plausible and acceptable by patients leading to increased dropout rate. On the face of it, patients may
have little confidence in the efficacy of such a procedure, which appears in strong contrast to their
acquired neutralizing strategy.
3. Personal Characteristics of the patient: Rachman & Shafran (1998) have pointed out, selective
attention involving frequent scanning of threatening material, loss of confidence in memory and
inflated responsibility may all lead to increased resistance in treatment.
Sources associated with difficult and resistant behavior
1. Difficulties in assessing the problem: some features of OCD may interfere with the assessment
process. For example, patients may not want to disclose obsessional cognitions, as they fear that
these might trigger OCD sequences. Other aspects of OCD such as slowness, indecisiveness, as well
as checking and reassurance-seeking maneuvers that make it difficult to administer self-report
measures.
2. Inadequate therapeutic relationship: OCD patients suffering from their disorder for a long time can
be quite ambivalent or confused about entering a therapeutic relationship. Their suffering may
suggest to them that something needs to be done, but there may be a little confidence that something
can be done.
3. Problems with environmental support: It can be considered a bad start when OCD sufferers are
coerced into treatment by their partners or other members of the family. Clinical experience suggests
that such extrinsically motivated commitment is hardly a good basis for a constructive therapeutic
alliance. Such patients tend to look mainly for support and appear to be less interested in changing
their maladaptive behavior.
4. Complications caused by co-morbidity: OCD patients tend to have a complex pattern of co-
morbidity indicating high levels of suffering. Such complications might be exacerbated by a rigid
therapist who may focus exclusively on OCD symptoms thus overlooking complex co-morbidity that
might affect the patient. It is questionable whether OCD treatment should proceed in the presence of
severe co-morbidity involving psychotic and/ or personality disorders.
Management of treatment resistant OCD

o Wilhelm and Steketee (2006) describe a form of Beckian Cognitive therapy for OCD that does not
include prolonged exposure or restrictions of rituals but uses a variety of cognitive strategies and
behavioral experiments to help patients test their (faulty) hypotheses.
o To begin with, an introduction of the cognitive-behavior philosophy to the patient should instill the
belief that change is possible, but that it may require sustained efforts. Behavioral experiments or
ERP sessions should be planned and operationalised in great detail and a written protocol to be
handed to the patient. All discussions about the objectives, stimulus situation, length, mode of
application etc., should take place before any session and it should be checked with the patient that
everything is understood and agreed. Those patients who have difficulties honoring verbal
agreements, a formal written contract may be envisaged, detailing all task requirements in an
operationalised format. This should be signed by all parties concerned. Despite these efforts, it is still
a possibility that patients neither understand nor accept the treatment rationale fully.
o Patients begin by identifying their own cognitive errors with the help of downward arrow technique
and Socratic questioning. Van Oppen et al., (1995) suggested that therapists do not challenge the
intrusions, but instead only examine the associated appraisal. Behavioral experiments can also be
used for the same. In addition, patients who overestimate danger are taught to calculate the
probability of harm with the help of pie technique. Patients are taught to entertain alternate
perspectives with the help of metaphors, stories, courtroom techniques etc. Mindfulness skills also
help patients tolerate discomfort.
CONCLUSION
The psychological treatment of OCD has greatly advanced over the last decade from a state of
stigmatizing pessimism to heady optimism. There are many opportunities to extend treatments to those
who previously did not respond, for more effective treatment implementation, for disseminating effective
treatments and perhaps even early intervention and prevention. This being so, the future needs to hold a
new set of apparently achievable aspirations; these are, how to ―cure‖ OCD earlier, more effectively, in
more people and more easily. It is also important to recognize the need to work out how to help those
people who ―partially respond‖.
DISCUSSION
INTRODUCTION
Despite the widely recognized efficacy of behavioral and cognitive treatments for OCD, there are major
challenges to implementing them successfully. At each step of the treatment process, it appears that a
substantial portion of the OCD population fails to benefit from the most effective psychological treatment
available. One reason for this poor outcome may be the fact that OCD is a complex and heterogeneous
disorder that may not lend itself well to general interventions. It is also associated with features that can
complicate the design, application, and delivery of treatment, such as treatment ambivalence, poor insight,
and high comorbidity.
PSYCHOLOGICAL THEORIES OF OCD
Psychoanalytic Theory: Critical Evaluation

Psychoanalytic theorists see obsessive compulsive personality disorder and obsessive compulsive
disorder on the same continuum, possessing the same anal-erotic trait premorbidly. This trait, which
constitutes the ―obsessional personality,‖ is a triad of characteristics almost always found together –
orderliness, parsimoniousness and obstinacy. However, a number of studies have failed to demonstrate
links between bowel movements and toilet training in childhood, and anal-erotic traits. Even if these
could be shown, they could be interpreted as functions of childhood training in general as subject to the
rigid, obsessional practices of a parent rather than due to specific repressive toilet training. Also these
traits were common among healthy people and are sometimes indiscoverable in people with obsessive
compulsive neurosis (Menzies & de Silva, 2003).
Behavioural Theory: Critical Evaluation

The behavioural theory of OCD was based on learning theory; particularly the two-factor model of fear
and avoidance.
There are multiple strengths of the behavioural model:
 It has empirical support as demonstrated in a series of now classic experiments in which exposure
to obsessional stimuli resulted in increased anxiety, and performance of compulsive behaviour
decreased this anxiety.
 The behavioural approach is based on the assumption that learning processes involved in the
maintenance of OCD are normal and that there is nothing pathological about the occurrence of
unwanted intrusive thoughts per se.
 An effective treatment for OCD, exposure and response prevention (ERP) is derived directly from
this model and the notion that OCD patients have developed avoidance and escape habits that
prevent the natural extinction of obsessional anxiety.
Behavioural theory has been criticized for its failure to differentiate between the theoretical
conceptualization of the range of anxiety disorders. That is, the theory does not explain some of the
clinical phenomena that are peculiar to OCD, such as the observation that the presence of a therapist
decreases obsessional anxiety and compulsive checking. One of the factors that lead to the development
of cognitive account of OCD was that behavioural theories did not seem to explain the occurrence of
obsessions without compulsions (Abramowitz & Houts, 2005).
Cognitive Behavioural Theory: Critical Evaluation

Self-report questionnaires and various laboratory experiments have supported the predictions of cognitive
models. Studies have found support that people with OCD have an inflated sense of responsibility, when
compared to people with other anxiety disorders and nonpatients. Evidence in support of Rachman‘s
theory include that cognitions can cause anxiety, that patients report that their obsessions are meaningful,
and the presence of cognitive biases such as thought–action fusion.
Salkovskis’ model which emphasises responsibility of appraisals and beliefs, has been criticized for
being silent on motivational components specific to the disorder, not able to explain why people are upset
by their appraisals, failing to account of the repetitive quality of obsessional symptoms, and disregarding
emotional concerns as factors in etiology and maintenance (Abramowitz & Houts, 2005).
RATING SCALES AND THEIR EFFICACY IN OCD MANAGEMENT
NAME OF THE SCALE STRENGTHS WEAKNESSES

Yale-Brown Obsessive  Excellent inter-rater  Poor discriminant
Compulsive Scale (Y-BOCS) reliability. validity.
 Subscale scale
preferable to
circumvent the problem
of poor discriminant
validity.
 Computerized version
also available.
National Institute of Mental  Excellent 2-week test-  Limited psychometric
Health Global Obsessive retest reliability. data available
Compulsive Scale (NIMH-  Sensitive to treatment-  Does not capture
GOCS) induced changes in information about the
symptoms. nature symptoms and
their severity.
Maudsley Obsessive  Good internal  Poor psychometric
Compulsive Inventory (MOCI) consistency and test- properties of slowness
retest reliability. and doubting subscales.
Maudsley Obsessive  Adequate internal  Poor discriminant
Compulsive Inventory-Revised consistency and validity of certain
(MOCI-R) convergent validity subscales (such as
cleaning).
Padua Inventory (PI) and  Both have excellent  Discriminant validity
Padua Inventory-Revised (PI- internal consistency and appears to be
R) reasonable test-retest problematic
reliability.  Several areas are not
 Addressed reasonable addressed, such as
range of obsessions and neutralizing and
compulsions, including hoarding.
ruminations and
impulses.
Leyton Obsessional Inventory  Reasonable internal  Less sensitive to
(LOI) consistency and treatment-induced
convergent validity. changes in symptoms.
Obsessive-Compulsive  Comprehensive  Psychometric properties
Inventory (OCI)  Strong psychometric of hoarding subscale are
properties. problematic.
 Addresses hoarding and
mental neutralizing
Children’s Yale-Brown  Good reliability and
Obsessive Compulsive Scale validity.
(CY-BOCS)
Leyton Obsessive Inventory –  Widely used  Poor test retest
child version (LOI-CV) reliability.
In summary, some instruments have been found to be more thorough and psychometrically sound than
others, with the Y-BOCS being the most comprehensive. However, there are two important domains that
mainstream OCD measures have neglected—the assessment of both cognitive appraisal and other
cognitive constructs related to OCD (Menzies and de Silva, 2003).
EFFICACY OF PSYCHOTHERAPY IN OCD
Efficacy of Psychoanalytic Therapy in OCD

Several of the articles and case reports acknowledge the limitations of psychoanalysis for OCD in terms
of its ineffectiveness, and argue against its utility in integrating it with other interventions. Psychoanalysis
has been used to help engage people with OCD to undertake other forms of treatment such as CBT, and in
conjunction with pharmacotherapy and behavioural treatments in both adults and children. However, such
combination treatments tell us little about the effect of each individual intervention, and the absence of
outcome measures precludes any conclusions regarding treatment efficacy (NCCMH, 2006).
Efficacy of Behaviour Therapy in OCD
Exposure and Response Prevention (ERP)
 Across 13 ERP studies it was found that the majority of OCD patients who undergo treatment
with ERP evidence substantial short-and long-term benefit.
 In another study, ERP was compared to anxiety management training (AMT), a credible placebo
treatment consisting of breathing retraining, relaxation, and problem solving therapy. On average,
patients receiving ERP improved almost 62% from pre-treatment to post-treatment on the Y-
BOCS, with end-point scores again in the mild range. In contrast, AMT groups showed no change
in symptom after treatment.
 To examine the efficacy of ERP with the addition of cognitive restructuring for OCD patients
with severe obsessional thoughts without overt compulsive rituals, a treatment programme was
derived from cognitive models of obsessions and involved the use of primary imaginal exposure
to intrusive anxiety-evoking thoughts and images. On average, patients attended between 25 and
30 twice-weekly and weekly treatment sessions. Compared to the wait-list group, the treatment
group evidenced encouraging results.
 One RCT found group and individual behaviour therapy were equally efficacious but with a faster
response rate for individual therapy. However the individuals were not typical of the OCD
population as they were OCD treatment naive and did not have any co-morbid psychiatric
conditions.
Results from numerous studies demonstrate the efficacy of ERP in reducing OCD symptoms; moreover,
most patients maintain their gains following treatment. A number of RCTs have found that ERP is
superior to a variety of control treatments, including placebo medication, relaxation, and anxiety
management training (Foa, 2010).
Thought Stopping
One of the oldest (and still most widely used) behavioral interventions for OCD is thought stopping.
Despite its wide use, however, empirical results for the use of thought stopping have generally shown this
technique to be ineffective for OCD (NCCMH, 2006).
Relaxation Training
Relaxation training has a long-standing history as a treatment intervention in medicine and mental health.
Some authors have suggested that progressive muscle relaxation (PMR) is a useful component of OCD
treatment, particularly with children. But mostly PMR strategies such as relaxation have not been shown
to be an effective component of treatment for OCD (NCCMH, 2006).
Efficacy of Cognitive Behavioural Therapy in OCD

A systematic review by Abramowitz (1997) found no significant difference between behaviour therapy
and cognitive therapy. Another randomized control trial (RCT) found a similar response rate following
behavioural and cognitive therapy. Obsessive cognitions changed with BT and CT.
The first study to examine the effectiveness of ―pure‖ CT versus ―pure‖ ERP was conducted by and the
results indicated significant improvement in OCD symptoms from both CT and ERP after six sessions
and after 16 sessions. After six sessions, brief ―pure‖ CT was as effective as brief ―pure‖ ERP. After
session 16, CT patients improved significantly more than did ERP patients on measures of OCD,
suggesting again that CT with behavioural experiments was at least as effective, and perhaps more so,
than self controlled ERP. Results also showed that CT patients were relatively more improved than were
ERP patients on measures of anxiety/discomfort associated with OCD symptoms and depression,
suggesting (as in previous studies) that CT may have broader clinical effects than does ERP alone. It was
also found that CT patients improved more than did ERP patients on measures of irrational beliefs
suggesting that CT‘s therapeutic effects may be related to its ability to modify distorted beliefs.
Clinical trials have shown DIRT to be an effective treatment. Although DIRT as a standalone therapy
seems to offer some advantages over conventional CBT, it may function currently more as an adjunct to
help cognitive restructuring. Findings indicate that DIRT may be a viable option for treatment-resistant
cases of compulsive washing (Herson & Sledge, 2002).
In a comparison of group CBT and ERP, it was found that both treatments were superior to waiting-list
control, with ERP being slightly more effective than CBT at the end of treatment and at three-month
follow –up (Abramowitz, 2007, Foa, 2010).
Neurofeedback
While neurofeedback (NF) has been extensively studied in the treatment of many disorders, there have
been very few published reports on its clinical effects in the treatment of obsessive compulsive disorder
(OCD). Hammod (2003) found improvement in OCD symptoms post treatment on Y-BOCS, Padua
Inventory and MMPI-II, alongwith accompanying depression, anxiety and somatic symptoms. Surmeli et
al (2011) found significant improvement in OCD symptoms of 36 drug resistant OCD patients, who were
assigned QEEG-guided neurofeedback session, as measured by MMPI and Clinician‘s Global Impression
(CGI). The results of these studies encourage further controlled research in this area.
Clinical Case Reports in OCD

THERAPY RESEARCH FINDINGS
Yogic Meditation Kundalini Yoga Meditation superior to relaxation response plus
mindfulness meditation.
Hypnosis Case reports generally reported improvements but there validity is
restricted by uncontrolled conditions.
Homeopathy Improvement in symptoms
Marital/Couple Therapy Research suggested efficacy of marital therapy during in-patient stay,
however all clients relapsed on returning home.
One study found improvement in client, when used affect regulation and
attachment focused treatment with client and their partner.
Transcational Analysis Research primarily revolved around the description of treatment
technique.
Many of the difficulties encountered in the above reviews were lack of control conditions and small
sample, thereby limiting any conclusions that could be drawn (NCCMH, 2006).
SPECIAL CONSIDERATIONS IN ERP
Procedural variations in ERP

 Meta-analytic studies suggest that the greatest effectiveness is achieved when therapist guided
exposure sessions are held multiple times per week, as opposed to once a week (Abramowitz,
1997). This is probably because shorter intersession intervals prevent the return to maladaptive
behaviours such as avoidance and rituals that maintain obsessional fears.
 Research also indicates that limited number of sessions may be needed to produce substantial and
durable symptom reduction. It is therefore recommended that an initial course of therapy be
limited to about 15 to 20 sessions.
Using Cognitive Techniques during Exposure Therapy

 One of the less well-described components of exposure therapy is the use of more or less informal
cognitive therapy techniques during the exposure sessions.
 The therapist should take an active role in facilitating cognitive change during exposure by
helping the patient challenge dysfunctional beliefs about feared stimuli and feared consequences
relevant to the exposure exercise. Rather than argue with the patient about their most feared
consequences, it is useful to emphasize the practicalities of taking low-level risks presented
during exposure. That is, learning to take such risks is preferable to the consequences of trying to
eliminate all risks (i.e., avoidance) or performing compulsive rituals to secure an absolute
guarantee of safety, which is not feasible. This is for the patient to discover through experiment
that exposure situations are ―not dangerous.‖
Mechanisms of Action of ERP

How does exposure therapy reduce the symptoms of OCD? Exposure helps patient correct their
overestimates of the likelihood and severity of negative outcomes that underlie obsessional fears. For
such cognitive changes to occur, three criteria are necessary.
 First, the situations and stimuli chosen for exposure must match closely with the patient‘s
obsessional fear to evoke subjective distress and physiological arousal.
 Second, exposure must be prolonged (perhaps 60 to 90 minutes) so that the patient experiences
the habituation of fear while still exposed to the feared stimulus (within-session habituation).
 Third, exposure tasks must be repeated so that the intensity and duration of the initial fear
response at the beginning of each exposure session declines with successive session (between-
session habituation).
Predictors of Treatment Outcome in ERP

A number of factors have been identified as predictors of poorer response to ERP.
 These include presence of extremely poor insight into the senselessness of OCD symptoms,
severe depression, generalized anxiety disorder, extreme emotional reactivity during exposure,
and severe borderline personality traits. Whereas some have found that more severe OCD
symptoms predicted poorer outcome, other studies have not found such a relationship. However,
consistent evidence is emerging to suggest that patients who present primarily with hoarding
symptoms respond less well to ERP.
 Several studies have also found a relationship between adherence with ERP instructions and
treatment outcome. It was found that better outcomes were associated with understanding the
rationale for ERP and adhering to the therapist‘s instructions for conducting in-session and
homework exposure tasks.
 Hostility from relatives toward the identified patient is associated with premature dropout from
ERP and with poor response among patients who complete treatment. It was also found that when
relatives express dissatisfaction with patient‘s symptoms, but do not express personal rejection,
such constructive criticism may have motivational properties that enhance treatment response.
This underscores the importance of educating family members about OCD and how to assist with
ERP (Abramowitz, 2007).
COGNITIVE VERSUS BEHAVIORAL THERAPY FOR OCD: WHAT WORKS BEST FOR
WHOM?
The efficacy of ERP for OCD has been well documented and there is now a growing body of research
reporting encouraging results of CT for OCD. However, there is no indication of categorical superiority
of one treatment over the other for all OCD patients. Hence, the question arises: are there patients for
whom one treatment may be preferable? Issues like this and related ones are discussed below:
Treatment Acceptance and Compliance

 Exposure and response prevention is an effective treatment for OCD, but despite its effectiveness,
at least 10% of ERP completers fail to respond, and another 20% relapse.
 Moreover, because of the demanding nature of this therapy, many patients refuse to undertake it.
Refusal rates are generally estimated at 30%. In addition, among those who do undertake ERP,
many show poor compliance, which is a predictor of poor response. Moreover, many patients
eventually drop out of treatment. Dropout rates are variable and likely depend on many factors;
some estimate ERP dropout rates as high as 40%.
 On the other hand, few patients refuse CT. Some researchers suggest CT techniques may increase
compliance with treatments that include anxiety-provoking exposure exercises.
Availability
 Unfortunately, therapists in most clinical settings are often unable (or unwilling) to schedule long
and frequent sessions outside of their offices, making the provision of strong ERP somewhat
impractical.
 Additionally, owing to the demands of ERP, many students do not receive adequate training in
ERP procedures, whereas most students do receive training in CT techniques. The relatively
lower number of ERP trained therapists likely detracts from its implementation given that CT
trained therapists are more available in real world settings.
OCD Symptom Subtypes

Although OCD is a highly heterogeneous condition, most studies do not examine how patients with
different symptom presentations respond to treatment.
 Furthermore, most research on ERP has excluded patients with symptoms such as exactness,
hoarding, counting, and slowness, focusing instead on those with primary checking and washing
compulsions.
 Some of these studies have shown that patients with checking rituals respond relatively less well
to ERP than do those with primarily washing compulsions. Perhaps in accordance with this, trend
level results in one study suggest the relative superiority of CT over ERP for patients with
primary checking symptoms.
 However, given that many treatment studies have employed sample sizes that are too small to
allow for meaningful comparisons among symptom subtypes, no consistent trends have emerged.
Clearly, additional research is needed before strong claims can be made about the relative
superiority of CT over ERP for specific OCD symptom subtypes.
 There is some evidence that CBT in patients with religious and sexual obsessions is less
effective. Religious patients suffering from blasphemous obsessions often refuse ERP, since they
experience such instruction as sinful. Some authors have suggested using cognitive therapy (CT)
techniques to increase adherence to ERP, although to date, this suggestion has not been studied
empirically.
 However, ERP remains the treatment of choice for those with sexual obsessions, with cognitive
therapy as a possible second-line alternative. People with sexual obsessions are less likely to have
overt rituals, and more likely to engage in mental compulsions and repeated reassurance-seeking,
so special attention should be given to covert rituals during treatment.
 As access to clinicians trained in CBT for compulsive hoarding is limited, a Web-based self-help
group has also been examined for its effectiveness.
 Future cognitive-behavioral approaches should also target the information-processing deficits that
appear to be present in patients who have the compulsive hoarding syndrome, including faulty
decision making and deficits in organization/categorization (Abramowitz, 2007).
Maintenance of Treatment Gains
The long-term effectiveness of ERP is fairly well established. However, methodologically sound,
controlled trials designed to measure long-term effectiveness of CT are very much needed.
CHANGES IN BRAIN MECHANISMS AFTER PSYCHOTHERAPY

Psychotherapy has been found to alter various brain mechanisms which were earlier disturbed, in various
mental illnesses. Schwatrz et al (1996) treated nine OCD patients with 10 weeks of behaviour therapy and
found significant bilateral decreases in caudate glucose metabolic rates that were greater than those seen
in poor responders to treatment. Before treatment, there were significant correlations of brain activity
between the orbital gyri and the head of the caudate nucleus and the orbital gyri and the thalamus on the
right. These correlations decreased significantly after effective treatment.
Nedeljkovic et al (2011) found that successful treatment with cognitive behavioural treatment of OCD led
to improvements relative to the control group on neuropsychological tasks measuring spatial working
memory.
MANAGEMENT OF CHILDHOOD OCD

Management and treatment is often complicated in children and young people with OCD as they
frequently have other comorbid problems.
What is the most effective format for treating children and young people with OCD?
Very few studies in the literature have taken a purely individual format of treatment.
 Researchers have attempted to empirically investigate the role of involving parents in CBT
protocols. The results indicate that children reported less distress associated with their rituals
(decreased SUDS ratings) when their parents were involved in therapy and were taught to ignore
their compulsions.
 One single case design study, and one case report, found that extinction, practiced by the parents,
was effective in decreasing compulsive reassurance seeking.
 One RCT investigated group formats of CBT and showed no difference between individual and
group formats.
 Two open clinical trials investigated group formats of CBT treatment with young people.
Preliminary results indicate that group formats of treatment may be an effective format of
treatment, but both studies also incorporated parent sessions (NCCMH, 2006).
 Simons, Schneider, et al. (2006) examined the effects of metacognitive treatment for OCD in
children and adolescents. The treatment combined the metacognitive treatment with elements of
CBT, so it is not possible to disentangle the relative contribution of modalities. However, the data
suggested that this treatment might be a useful alternative to exposure and response prevention.
Are there developmental differences in the treatments most likely to achieve improvements in the
identified outcomes for children (aged 8 –11 years) and young people (12–18 years)?
Most of the intervention studies have concentrated upon the adolescent age group (12–18 years). The
studies which have focused on children aged 11 years and have highlighted the usefulness of CBT
protocols, ERP and extinction with younger children (NCCMH, 2006).
COMBINING MEDICATION AND PSYCHOTHERAPY IN OCD

RESEARCHERS METHODOLODY RESULTS
Van Balkom et al (1998) Four groups: ERP, Cognitive ERP fared somewhat less well
Therapy (CT), ERP plus in this study than in other
Fluvoxamine, and CT plus RCTs. A likely explanation for
Fluvoxamine the relatively disappointing
improvement rate of 32% is that
the ERP protocol was less than
optimal: all exposure was
conducted as homework
assignments.
Foa et al 2005 Two groups: Serotonin SRI with ERP yields superior
Reuptake Inhibitor (SRI) alone outcome compared to SRI
and ERP plus SRI alone.
Foa and Liebowitz et al (2005) Four groups: intensive ERP, ERP produced a 50% Y-BOCS
antidepressant clomipramine reduction, which was far
(CMI), ERP plus CMI, and pill superior to the effects of pill
placebo. placebo. ERP was also more
effective than CMI but not
ERP+CMI (which was
equivalent to ERP alone).
Overall, the findings from
RCTs suggest that ERP
produces substantial and
clinically meaningful
improvement in OCD
symptoms and that symptom
reduction is due to the specific
effects of these treatment
procedures.
O’Kearney et al (2010) Meta analysis of overall Behaviour/cognitive behaviour
efficacy of BT/CBT for therapy effective treatment for
paediatric OCD, its relative childhood OCD.
efficacy against medication. BT/CBT alone reduces the
severity of OCD symptoms and
is atleast as effective as
medication.
Less evidence that BT/CBT
when combined with
medication may result in greater
reduction in OCD symptoms
relative to what can be achieved
with medication alone.
CRITICAL ISSUES IN OCD: SPECTRUM AND COMORBIDITIES
Paraphilias (sexual deviation)

The vast majority of research on treatment effectiveness with paraphilias has been conducted with sexual
offenders. Most sex offenses, however, are not the expression of paraphilia. We are not yet at a point
where we can say that a specific psychotherapeutic treatment is uniquely effective for any one paraphilia
or for all types of paraphilia.
There is substantial psychoanalytic and psychotherapeutic literature on the treatment of some forms of
paraphilia. Marital therapy and expressive group psychotherapy have been found to be effective. Covert
sensitization, aversive therapy, satiation and masturbatory reconditioning were used in the treatment of
sexual offenders in United States, but the evidence in support of their values was not remarkable (Hersen
& Sledge, 2002).
Bulimia Nervosa
Extensive evidence supports cognitive behavioural therapy (CBT), in individual, or in group format, as
the first-line treatment, with interpersonal therapy (IPT) a close second. Most trials use the modification
of CBT manualised as ‗CBT-BN‘ by Fairburn (1993) or similar adaptations, such as that of Cooper
(1995). Treatment is effective in individual or group format and even in self-help, or guided self-help
format (Cooper, 1996). There have recently been pilot studies of telephone delivery and internet delivery.
In a one year follow-up study, IPT subjects catch up with the CBT cohort on all measures of functioning,
including binge-purges (Fairburn et al., 1995).
Anorexia Nervosa
The Maudsley group has compared individual focused dynamic therapy with dynamically informed
family therapy and with individual cognitive analytic therapy (CAT) in a sample of low-weight
outpatients over the course of a year. The study faced the challenge of studying severely ill anorexic
patients managed as outpatients and demonstrated the benefits of continuity of therapist and of therapist
expertise. Nothing can be concluded about the specific model of therapy provided.
In a 5-year follow-up comparison of family therapy and individual supportive therapy, both treatments
had produced significant improvements. Patients with early onset and short history of anorexia nervosa
appeared to do better with individual supportive therapy.
Hypochondriasis
Current treatments of choice for hypochondriasis include a variety of medications and CBT. The most
extensively tested psychosocial intervention for hypochondriasis is CBT. Substantial improvements with
CBT were found, over wait-list controls and medical care as usual. CBT and ERP, both were found to be
equally effective.
Whether to choose CBT or exposure therapy, an argument could be that CBT is the logical, initial choice
given that it has been more extensively tested in randomised controlled studies. Exposure-based
treatments, however, may be indicated in cases where another disorder may be present (eg., OCD) or
when the illness concerns are present with especially repetitive and/or exacting checking routines
(Abramowitz, 2007).
Intermittent Explosive Disorder (IED)

Data from psychotherapy trials for individuals with IED are limited, with suggestions that insight-
oriented psychotherapy and behavioral therapy might be helpful for some individuals. A specially
designed CBT (included techniques like time-out, and increase emphasis on aggression and relapse
prevention) in the treatment of IED, was also found to be effective (Aboujaoude & Koran, 2010).
Pathological Gambling (PG)

In PG, the 12-Step program Gamblers Anonymous is arguably the most widely used intervention, and
existing data suggest that those who attend fare better than those who do not. Behavioral therapies helpful
for individuals with PG include motivational enhancement or interviewing and cognitive-behavioral
therapy (Aboujaoude & Koran, 2010).
Tourette and Trichotillomania

Habit reversal therapy appears effective in Tourette and trichotillomania. Habit reversal conceptualizes
hair-pulling as one of a range of different stereotypes (e.g., skin picking) that people may experience.
Treatment compliance is an important predictor of treatment response, and a number of strategies can be
used to increase it. Behavior reward programs can reward completion of homework and other therapeutic
tasks. This strategy is particularly useful and practical in treating children. For adults, a self-imposed
reward program may be used in which the patient rewards herself or himself for completing certain
therapy tasks. In addition, the therapist should attempt to link the patient‘s treatment compliance to values
the patient holds. In addition to HRT and stimulus control procedures, cognitive restructuring is
sometimes used to target maladaptive thoughts surrounding pulling. In a randomized trial with 34
participants, HRT was also found more effective than negative practice in reducing the number of hair-
pulling episodes (Aboujaoude & Koran, 2010).
.
Body Dysmorphic Disorder
Exposure and response prevention appears efficacious for BDD. However, reports of this technique—
without concomitant use of cognitive approaches—is limited to a retrospective study and small case series
with up to 10 subjects. Habit reversal is frequently needed when treating patients with BDD, especially
for common BDD symptoms such as skin picking. There certain unanswered questions which require
further study like whether the greater delusionality in BDD requires inclusion of a cognitive component to
explicitly target poor insight and greater focus on motivation and engagement in therapy (NCCMH,
2006).
Pyromania
Non-pharmacological interventions for fire setters, including forms of cognitive-behavioral therapy
counselling and day treatment programs, have shown some efficacy. There have been some encouraging
results were reported with the use of aversive stimuli, a combination of aversive stimuli and positive
reinforcement, alternative behavior substitution, procedures for stimulus satiation, and complex schedules
of reinforcement. In addition, cases in which psychodynamic psychotherapy was used have also been
reported. Because marked disturbance in family relationships has been found in many cases of recurrent
fire-setting behavior by children, family therapy methods have been used (Aboujaoude & Koran, 2010).
Kleptomania
From the 1920s to the 1950s, psychoanalytic therapy was the preferred treatment for kleptomanics,
whether referred by courts or their own families but was found to be less effective.
Several behavioral strategies have been reported effective in case reports, including covert sensitization
using aversive imagery of nausea and vomiting; aversion therapy involving aversive breath holding (until
mildly painful) whenever an urge to steal or an image of stealing is experienced; systematic
desensitization; and imaginal desensitization involving relaxation training coupled with imagining a
stealing scene and the adverse consequences while the therapist suggests that the patient can control the
stealing urge. Informational books and self-help guides are also available (Aboujaoude & Koran, 2010).
Comorbidities in OCD
Treating Patients with Co-morbid Panic Disorder or Panic Attacks

When patient‘s have panic attacks or panic like symptoms only in response to OCD triggers, it is
important to learn about these idiosyncratic fears to tailor psychoeducation and set up exposure in such a
way that patient can test out their beliefs.
Treating Patients with Comorbid Social Phobia

It is occasionally necessary, however, for clinicians to address social concerns concurrently with OCD
concerns, particularly when exposures involve other people. There are times when co-occurring social
phobia must be treated before initiating treatment for OCD, such as when group treatment for OCD is the
only available option.
Treating Patients with Co-morbid Posttraumatic Stress Disorder

Because many patients with PTSD experience intrusive thoughts and exhibit compulsive behaviors that
have some functional relationship to the trauma they experienced, it is appropriate for clinicians to
proceed with PTSD treatment to deal with both of these difficulties. Often, the best way to decide which
disorder to treat first is to ask the patient which is causing the most significant distress and impairment.
Treating Patients with Co-morbid Generalized Anxiety Disorder

GAD rarely interferes to such a degree that OCD treatment is not feasible. Rather, patients may have a
hard time focusing on OCD treatment; they may want to discuss both obsessions and worries because
they do not distinguish between these states in the same ways that clinicians do. In such situations,
patients can be educated about the difference between OCD and GAD and can be encouraged to try to
focus on OCD for the allotted time and then re-evaluate their GAD at the end of treatment. This dual
focus works particularly well when clinicians' methods for treating GAD are similar to their methods for
treating OCD.
Modifying Treatment for Patients with Co-morbid Obsessive-Compulsive Disorder and Bipolar
Disorder
Many patients with OCD also have a depression diagnosis. It has been found; only when depression is
very severe does it seem to interfere in treatment for OCD. In the case of severe depression, or when
patients are having prominent suicidal thoughts, it is always advisable for patients to seek treatment for
their depression first. With improved mood and energy and less risk of self-harm, patients will be much
more ready to focus on the hard work of OCD treatment. Perhaps CT techniques that are used for
postpartum depression could be added to ERP for depressed OCD patients. Engaging in CT to reduce
depressive symptoms prior to beginning ERP alleviates some depressive symptoms and helps the patient
to increase motivation and compliance with difficult exposure therapy assignments, thereby enhancing
reductions in OCD symptoms.
It is recommended that patients with bipolar disorder first receive treatment to bring their manic
symptoms under control before attempting ERP for OCD. When this approach is used, individuals can
often make good progress in reducing their OCD symptoms when they begin ERP.
Co-morbidity with Tics

The consensus among clinicians is that the presence of both Tics and OCD leads to greater treatment
difficulty. If tics and symptoms of OCD coexist in adults, they can usually be treated independently and
sequentially in either order, often depending on the priority of the client. The bigger problem comes when
the two interact with each other, especially if it is not clear to the clinician at what point the tics end and
the obsessions and compulsions begin. When tics and OCD become intertwined, it is usually in the
context of beliefs about superstition or bad luck.
SPECIAL ISSUE IN TREATMENT
Culture and OCD treatment

Culture plays an important role in presentation and management of OCD. An example of culture bound
syndrome related to OCD in India is ―Suchi Bai,‖ in which there is excessive concerns for cleanliness
(changes street clothes, washes money, hops while walking to avoid dirt, washes furniture, remains
immersed in holy river (Bengal, India—especially Hindu widows). The striking similarities between the
form and content of normal ritual (influenced by particular culture) and the ritualistic behavior of
obsessive compulsive disorder (OCD) invite a deeper analysis. However, there is no indication that
groups who are more heavily religious have a higher incidence of OCD. Thus we may infer that culture
may have an effect on the way OCD manifests itself, but does not increase its prevalence in a population.
When member of these religious groups use the religious content to rationalise or conceal their rituals, it
indicates ―poor insight,‖ which plays a role in management of these people.
It has been noted, in non-Western cultures nonmedical belief systems may influence help-seeking for
OCD. For example, among Egyptian and Turkish patients with severe OCD (especially those with
religious and sexual obsessions), treatment was considerably delayed, arguably on account of the shame,
guilt, and cultural taboo associated with these symptoms. Across countries, exposure and response
prevention is arguably the most effective psychological treatment for OCD currently available (50%–
60%), but no systematic cross-cultural comparative studies exist.
Preventing Relapse: Using an Eclectic Approach

Relapse prevention is an important issue in the management of OCD. A relapse prevention program was
tested on six patients with OCD. The program consisted of one psycheducational session about relapse
and brief phone contacts twice monthly for 6 months. All patients maintained gains on OCD symptoms
and anxiety, but depressed mood remained elevated up to a 2-year follow-up. Another study showed that
patients who received relapse prevention training following ERP were less likely to relapse at 6-month
follow-up than were those whose ERP was followed by an associative therapy (placebo) treatment. Thus,
effective relapse prevention requires specific, focused efforts to help patients reduce and manage the
occurrence of symptom increases.
Implications for Treatment Resistant OCD
One concern with regard to treatment resistance is that ERP may be rejected by up to 25% of patients as
simply too difficult to tolerate. When surveyed 15 clinic applicants with OCD who requested
psychological treatment from OCD clinic, 87% (all but 2) stated that they preferred to enter CT over ERP.
Further, dropout rates from our CT studies were low (about 10 to 15%), consistent with other studies that
have tested CT for OCD symptoms. Thus, this CT method may be less stressful to patients, even severe
ones, and more acceptable than ERP, leading more patients to choose this method and continue in
treatment.
Outcome data on OCD symptoms, depression, and beliefs using schema-based approach with two
samples of CBT resistant OCD patients, including all symptom subtypes found that previous cognitive
therapy and ERP had lasted over 2 years. Of the 39 patients, 32 (82%) showed clinically significant
improvement in OCD symptoms and depression.
OCD with Poor Insight

Several studies have shown that patients with poor insight are less responsive to behavioral therapy and to
pharmacotherapy — although there is not unanimity on this point in the literature, as other studies have
found no link between insight and response to CBT. In apparent contrast to these findings, other authors
found that OCD patients with poor insight did well with exposure, either alone or in addition to cognitive
therapy. Behavioral techniques aimed at enhancing insight and/or motivation may be potentially
beneficial in OCD. A recent study demonstrated that cognitive behavioral group therapy was more
effective if preceded by two individual sessions of motivational interviewing and thought mapping. The
symptom reduction was still maintained at a 3-months follow up (Meyer et al., 2010).
NEWER TRENDS IN PSYCHOLOGICAL TREATMENT OF OCD
Metacognitive Therapy in OCD

 A number of correlational studies have demonstrated that metacognitive beliefs are positively
correlated with obsessive-compulsive symptoms.
 In a different evaluation of metacognitively delivered exposure in OCD, the relative effects of
brief exposure and response prevention configured as a metacognitive experiment were tested
against exposure and response prevention with a habituation rationale. The metacognitively
delivered exposure and response prevention produced significantly greater reductions in anxiety,
urge to neutralize, and negative beliefs than the habituation condition.
 Metacognitive therapy was used on four OCD patients, and found substantial improvement, even
after 6-month follow-up.
 An open trial of group MCT for patients suffering from OCD was conducted and outcome was
assessed using the Y-BOCS and metacognitions were assessed with the MCQ-30. Statistically
significant improvements were found in OCD symptoms measures at posttreatment. Gains
continued to be made over the 3-month follow-up (Fisher & Wells, 2009).
Acceptance and Commitment Based Therapy (ACT)

Although it appears that ACT can lead to meaningful clinical outcomes in OCD, without necessarily
using traditional exposure procedures but much more work is needed to develop this approach.
In a multiple baseline with four adults diagnosed with OCD, eight weekly one-hour sessions of ACT
without in-session exposure had a significant impact on OCD severity, depression, and anxiety. OCD
severity scores moved from the clinical to the nonclinical range and results showed near zero levels of
compulsions by the end of treatment, with results maintained at follow-up.
In another study, ACT resulted in a greater number of participants showing clinically significant
improvement compared to Progressive Relaxation Training (PRT) and had a significantly greater effect
on depression. Quality of life improved in both conditions but was marginally in favor of ACT at post.
And, psychological constructs thought to be associated with ACT showed greater change in the ACT
condition than in PRT, at least initially. All of this suggests that an ACT model appears to be broadly
applicable to an OCD population (Twohig et al 2010).
.
Virtual reality therapy
Virtual reality (VR) is one of the best candidates as a tool for assessing and treating OCD patients. VR
integrates real-time computer graphics, sounds, and other sensory input mechanisms to create a computer
generated world with which the user can interact. Because of these features, VR can serve as an
alternative, patient-friendly assessment and treatment tool for OCD patients. VR-based therapy is based
on the principle of exposure similar to traditional approaches. However, VR offers a safer and cost-
effective alternative, in some conditions, compared to the traditional approaches, in which vivo exposure
is impractical, difficult, and potentially dangerous (e.g. driving phobia). Nonetheless, the use of VR for
OCD is still in short supply, possibly due to the heterogeneous symptoms of OCD and poor understanding
of the link between VR and OCD. Recent findings indicate that behavioral tasks using VR are capable of
measuring a range of behavioural parameters associated with OCD symptoms (Kim et al 2009).
Self-Help Books and Computer Programmes
There are many self-help books for OCD, such as Living with Fear and The OCD Workbook. An
international group has developed and tested a computer-administered system called BT STEPS, for
assessing and treating OCD via the telephone and computer. A trial of 218 patients compared the
computer guided behaviour treatment to clinicial-guided behaviour treatment and relaxation. The
relaxation was ineffective, whereas both the behaviour therapy conditions were effective, with a
significantly greater improvement in the clinician-guided group. Patients in the computer-guided
treatment group improved more the longer they spent telephoning the computer and doing self-exposure.
Benefits of this computer treatment include saving the time of the therapist for clients who do not benefit
from self-administered treatments, enabling users from all locations to access as much therapy time as
they want, and at the time they want it. Internet based Cognitive Behaviour Therapy (ICBT) with
therapist support reduces OCD symptoms, depressive symptoms and improves general functioning.
Randomized trials are needed to confirm the effectiveness of this new treatment format (Abramowitz,
2007).
CIP STUDIES
Josesph, G.A. and Das, B. (2006) studied the efficacy of neurofeedback in obsessive compulsive disorder.
Overall findings were concluded as neurofeedback found to be efficacious in certain symptoms of OCD
than OCD per se; improvement in global impairement, time spent on obsessions, interference from
obsessions and distress from obsessions.
Lenka, P. and Sinha, V.K. (ongoing PhD thesis) studying the role and efficacy of neurofeedback in
obsessive compulsive disorder.
Psychosocial Unit in CIP runs an OCD clinic, once a week where therapy is done in a group setting. It‘s
an open group and has 4-6 members with 20-25 members coming in a month. Most of the patient‘s are
also undergoing individual therapy. Further research can be directed to explore the role of this group
intervention in symptom reduction and maintenance.
CONCLUSION
Over 40 years of published research has led to the wide consensus among researchers and clinicians that
CBT is an effective treatment for OCD. Exposure-based treatments have the largest evidence base to
support their use for OCD. ERP which includes processing appears to be most effective, whereas
exposure without processing and CT produced equivalent improvement. Based on the large empirical
evidence for ERP it is recommended as the first-line treatment for OCD, with CBT as an alternative.
More work also needs to be done to determine how to best tailor treatment to individual needs. Most
OCD sufferers have comorbid disorders, but studies typically exclude participants with other anxiety
disorders, psychosis, or bipolar disorder; thus we do not know how effective treatments are for comorbid
populations. Future research should be focused upon these existing areas (culture, treatment resistant,
poor insight) and newer domains like Acceptance and Commitment based Therapy, Virtual Reality
Therapy and Self help books and programs.
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APPENDIX 1
Sakovskis’ model (1989) for OCD and inflated sense of responsibility as a core element
APPENDIX 2
Cognitive theory of Rachman (1997) and misinterpretation of intrusions as core element
APPENDIX 3
Cognitive Thought Control Model – Clark (2004)
APPENDIX 4
RATING SCALES USED IN OCD (Menzies and Silva, 2003)
Sno Name Description

1 Yale-Brown Obsessive It is clinician rated 10-item scale with ratings on a four-point
compulsive Rating Scale (Y- scale from 0 (no symptoms) to 4 (extreme symptoms). Total
BOCS) score ranges from 0 – 40, with separate subtotals for severity
of obsessions (sum of items 1 to 5) and compulsions (sum of
items 6 to 10). A separate form is also available for children.
2 Maudsley Obsessive Compulsive It is a 30-item, dichotomous (true-false) self rated
Inventory (MOCI) questionnaire that was developed to investigate the different
types of obsessive compulsive complaints in patients.
3 Leyton Obsessional Inventory It is a self rated 69 item inventory designed to assess

(LOI) obsessional symptoms and traits (46 on symptoms & 23 on
traits). However, it has poor reliability and validity and may
not be a good indicator of severity.
4 National Institute of Mental It is a rater rater-administered point scale (1 – 15 points) with

Health Global Obsessive five severity categories (1-3 – normal; 4-6 – subclinical OCD;
Compulsive Scale (NIMH- 7-9 – clinical OCD; 10-12 – severe; 13-15 – very severe).
GOCS)
5 Padua Inventory (PI) it is a 60-item self report measure rated on a five point scale
(0-4). Subsequent factor analysis led to the development of 41-
item revised inventory.
6 Obsessive Compulsive Inventory It is a 42-item self report measure rated on a five point scale
(OCI) (0-4) for both frequency and distress of symptoms.
7 Thought Control Questionnaire It is a 30-item questionnaire rated on a 4-point scale with 1

(TCQ) being never and 4 being almost always. It measures the
various techniques an individual uses to control unpleasant and
unwanted thoughts.
8 Hoarding Rating Scale Interview It consists of 5 questions intended to reflect dimensions of

(HRS-I) hoarding such as difficulty using living spaces due to clutter,
difficulty discarding possessions, excessive acquisition of
objects, emotional distress due to hoarding behaviors, and
functional impairment due to hoarding behaviors. Each item is
rated on a 9-point scale ranging from 0 (none) to 8 (extreme).
APPENDIX 5
PHASE Neutral I would like you to develop some experience of observing your thoughts in a
-I thought detached way without the need to engage with them. In a moment I‘m going to
slowly say a series of words and I want you to watch your thoughts without
influencing them in any way. Perhaps nothing will pass through your mind,
perhaps images or memories or feelings will pass through. I want you to watch the
passage of events in your mind in a detached way without reacting to them in any
way. Make yourself comfortable and try it with your eyes open. Let‘s start: tree . .
. blue . . . bicycle . . . birthday . . . chocolate . . . sea . . . orange juice . . . friend.
Obsession I‘m going to ask you to let your mind roam freely. Allow any thoughts to enter
your mind including the obsessional thought. Don‘t do anything with your
thoughts, just watch them in a detached way, allow your obsessional thought to
enter, but remain detached from it. It may change but don‘t make it change, it may
do nothing at all, it doesn‘t matter, just watch it in a detached way. See how you
are the observer of your thoughts, how they are separate from you, a thought is
just an event in the mind.‖
PHASE Neutral Close your eyes and have the thought of an apple. With that thought in mind, I
– II thought want you to take a step back from it in your mind, but keep the thought present.
It‘s as if you are moving away from it. Now focus on where you are in relation to
the apple. Notice how you are separate from that thought: the apple is simply an
event in your mind, but it is not part of you.
Obsession Let‘s now try that with an obsessional thought. Close your eyes and allow your
obsessional thought to come into your mind. With that thought in mind, take a
step back from it, but keep the thought present. Now focus on where you are in
relation to the thought. Notice how your sense of self is separate from the thought.
The obsession is simply an event in your mind, it is not an important part of you.‖
APPENDIX 6
CASE ILLUSTRATIONS (Taken from CIP Case Record Files)
Problem Technique Description of Treatment

Used
 A hierarchy was made of all the possible
Checking situations starting from the least anxiety
provoking situation to the most. The least
28 year old hindu married female anxiety provoking situation for the patient
with chief complaints of fear of was being near a slightly open door followed
getting scratch from any corner or ERP by being near to the edge of the wall and the
edge such as edge of a door or wall, most anxiety provoking situation being
rim of a cooker etc. washing the cooker as she felt that while she
will wash the cooker, the rim of it will hurt
her and lead to a scratch on her skin.
 The patient was exposed to each of the
situations systematically and the patient was
encouraged to tolerate anxiety while
preventing any kind of neutralizing behavior.
 Once the situation was mastered by the patient
such that the anxiety experienced by the
patient in that particular situation is minimal,
then we proceed to the next situation in the
hierarchy.
 Dysfunctional Thought Record was
Sexual Obsessions maintained.
Cognitive  Patient was encouraged to calculate
35 year old Christian married male Therapy probability estimates of engaging in a
with chief complains of having particular action.
intrusive thoughts of having a sexual  Cognitive Restructuring
intercourse with mother mary  Dealing with thought action fusion
Compulsive behavior – praying and  Courtroom Role Play
asking for apology from god.
Habituation Training
Mental Compulsions Written- Patient was asked to write about his
ERP mental compulsions every day especially during
21 year old muslim single male with the time when he is most bothered by these
chief complaints of mentally mental compulsions (generally when he is idle).
travelling to the places visited before
through different routes. Loop Technique - Subsequently, the content of
the mental compulsions were recorded and
patient was encouraged to listen to it repeatedly.
Washing  A hierarchy was made of all the possible

situations starting from the least anxiety
35 year old hindu married female provoking situation to the most. The least
with chief complains of fear of anxiety provoking situation for the patient
contamination and repeated hand was when her husband enters home and sits
washing and cleaning. on the bed without washing his hands and feet
ERP and the most anxiety provoking situation
being continuing her work without having a
bath after using the washroom.
 The patient was exposed to each of the
situations systematically and the patient was
encouraged to tolerate anxiety while
preventing any kind of neutralizing behavior.
 Once the situation was mastered by the patient
such that the anxiety experienced by the
patient in that particular situation is minimal,
then we proceed to the next situation in the
hierarchy.
Ordering/Symmetry  A hierarchy was made of all the possible
situations starting from the least anxiety
Index patient 45 year old muslim provoking situation to the most.
male with chief complains of ERP  Based on hierarchy, put things in a disordered
arranging all the books in height- manner
wise manner and inability to tolerate  Using Procrastination
creases on the bed sheet or table  Modifying Faulty beliefs
cloth.
Hoarding  Identify all the areas at home that are cluttered

 Make a plan about how to organize her home
Index patient 45 year old married ERP such that the plan includes the utility of the
Hindu female with chief complains places that are cluttered as well as other
of not throwing things that serve no places at home.
apparent purpose in the near future  An area is chosen based on the patient‘s
(eg: broken guitar wire, empty tray comfort or on basis of the ease with which the
of chocolate boxes, pens that do not place can be cleared.
work, broken buckets etc.)  Clear the clutter in the area chosen and put it
in wither of the three boxes made, ―Store‖,
―sell‖, and ―discard‖.
 Once the place is clear, start preparing for
utilizing the space as per the plan.

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Government of India

CENTRAL INSTITUTE OF PSYCHIATRY

CHAIRPERSON – Ms. Deyashini Lahiri

DEFINITION AND NATURE OF OBSESSIONAL EXPERIENCE (Krebs & Heyman, 2010)

- Contamination - Washing and Cleaning

THEORETICAL MODELS OF OCD

Biological Models (Sadock & Sadock, 2007)

Salkovskis‘ Cognitive-Behavioral Theory of OCD

Rachman‘s Cognitive Theory of Obsessions

Rating Scales used in OCD

Findings on Psychological Assessment (Marnat, 2003)

MMPI MCMI DAPT Rorschach TAT

THERAPEUTIC APPROACHES IN OCD

Common Modes of Treatment

Exposure and Response Prevention

Engaging in a ritual brings about Repeated exposure reduces the initial

ERP for common OCD problems (Hyman & Pedrick, 1999)

Ordering and Symmetry

I. Assessment of the hoarding problem

Cognitive therapy (CT)

TECHNIQUES USED IN COGNITIVE THERAPY FOR OCD

OCD Belief Domain-Specific Techniques

Techniques for Reducing Exaggerated Estimates of Responsibility

Techniques for Reducing the Need to Control Thoughts

Techniques for Reducing Overestimates of Danger

Techniques for Reducing the Intolerance of Uncertainty

Techniques for Reducing Perfectionistic Beliefs

Newer trends in Cognitive Behavior Therapy

Cognitive Bio-behavioral Self Treatment (Schwartz, 1996)

Metacognitive Therapy (MCT) (Wells, 2009)

Acceptance and Commitment Therapy (Harris, 2006)

Danger Ideation Reduction Therapy (Herson & Sledge, 2002)

Other Modes of Treatment

GROUP THERAPY IN OCD

MANAGING CHILDREN WITH OCD

OCD AND FAMILY MANAGEMENT

DEALING WITH SELF DEFEATING SAFETY BEHAVIOR

MANAGEMENT OF DISORDERS WITHIN THE OBSESSIVE COMPULSIVE SPECTRUM

Tics, Tourette and Trichotillomania

Body Dysmorphic Disorder (BDD)

MAINTAINING TREATMENT GAINS AND MANAGING RELAPSE

Clinical Features with difficult clients

Sources associated with difficult and resistant behavior

Management of treatment resistant OCD

PSYCHOLOGICAL THEORIES OF OCD

Psychoanalytic Theory: Critical Evaluation

Behavioural Theory: Critical Evaluation

Cognitive Behavioural Theory: Critical Evaluation

NAME OF THE SCALE STRENGTHS WEAKNESSES

EFFICACY OF PSYCHOTHERAPY IN OCD

Efficacy of Psychoanalytic Therapy in OCD

Exposure and Response Prevention (ERP)

Efficacy of Cognitive Behavioural Therapy in OCD

Clinical Case Reports in OCD

SPECIAL CONSIDERATIONS IN ERP

Procedural variations in ERP

Using Cognitive Techniques during Exposure Therapy

Mechanisms of Action of ERP

Predictors of Treatment Outcome in ERP

Treatment Acceptance and Compliance

OCD Symptom Subtypes

CHANGES IN BRAIN MECHANISMS AFTER PSYCHOTHERAPY