Obsessive compulsive and related disorders

Cognitive behavior model by salvoski

Trigger
e.g
Robbery

Intrusive thoughts

Door not locked, someone will enter

attentional\
reasoning bias
Compulsions
i.e over
e.g check door attending to
persistently external cues
Meaning of thoughts

e.g I’m responsible for the

safety

maintenance cycle Emotional

Avoidance\ safety reactions &
behaviors bodily
sensations
Avoid going out
i.e anxiety
More locks
 trigger

temporary
reduction in obessions
anxiety

saftey
behaviors interpreations

anxiety
 Baseline chart for thoughts
Situation Duration What was the Rating Strategies Consequences
thought used

What sets you How long did Tell about the Low 1 What did you Tell about the
up to you get thoughts you High 10 to control the consequences
overthink ? worried? were having thoughts
Baseline chart for compulsions

Situation Duration What was the Rating Strategies Consequences

behavior used

What sets you How long did Tell about the Low 1 What did you Tell about the
up to wash you get behaviors you High 10 to control the consequences
your hands? worried? were having behavior
 Etiology of OCD
Psychodynamic Approach

Psychodynamic theorists propose that anxiety disorders, particularly obsessive-compulsive disorder

(OCD), stem from the conflict between id impulses and ego defenses. Unlike other anxiety disorders, in
OCD people start to fear their own id impulses or thoughts, where this conflict remains largely
unconscious, in OCD, it manifests explicitly in thoughts and actions. For instance, someone with OCD
might repeatedly check things to counter obsessive thoughts.

Psychodynamic theorists identify several ego defense mechanisms common in OCD, including isolation,
undoing, and reaction formation. Isolation involves disowning undesirable thoughts, undoing involves
performing acts to nullify unacceptable impulses, and reaction formation involves adopting a lifestyle
opposing unacceptable impulses.

Freud attributed OCD development to intense conflict during the anal stage, where children experience
rage and shame while being toilet trained. Poor handling of this conflict could lead to obsessive-
compulsive symptoms later in life. However, not all psychodynamic theorists agree with Freud's
explanation; some suggest insecurity as a root cause instead.

Behavioral Approach

Behaviorists focus on explaining and treating compulsions in obsessive-compulsive disorder (OCD),

proposing that compulsions arise randomly. Individuals associate specific actions, such as hand washing
or dressing in a certain way, with a reduction in anxiety during fearful situations. Over time, they come to
believe that these actions bring good luck or actually change the situation, reinforcing the compulsive
behavior. Stanley Rachman's research supports this idea, showing that compulsions indeed reduce
anxiety.

Cognitive Approach

Cognitive theorists offer a promising explanation and treatment for obsessive-compulsive disorder
(OCD), integrating cognitive and behavioral principles into their approach, often referred to as cognitive-
behavioral therapy (CBT). They highlight that everyone experiences unwanted intrusive thoughts, but
those with OCD tend to blame themselves for these thoughts and fear their consequences, leading them to
engage in neutralizing behaviors to alleviate discomfort.

Neutralizing behaviors, such as seeking reassurance, engaging in rituals, or attempting to counteract

intrusive thoughts, temporarily reduce anxiety and are reinforced over time, eventually becoming
obsessions or compulsions. People with OCD may develop an increased fear of their intrusive thoughts,
leading to more frequent occurrences and reinforcing the cycle.

Research supports this explanation, showing that individuals with OCD experience intrusive thoughts
more frequently, employ elaborate neutralizing strategies, and experience reductions in anxiety after using
these techniques.
Everyone has intrusive thoughts but why only these people engage with them: according to research

1. They are more depressed than other people

2. They have exceptionally high standards of conduct a morality
3. They believe that their intrusive negative thoughts are equivalent to actions and capable of
causing harm to themselves or others
4. They believe that they can and should have perfect control over their thoughts and to feel
responsible for eliminating the imagined danger
Genetic Causes

Serotonin, a neurotransmitter involved in transmitting messages between neurons, has been implicated in
OCD due to the effectiveness of certain antidepressant drugs, such as clomipramine and fluoxetine, in
reducing symptoms. These drugs increase serotonin activity, suggesting that low serotonin levels may
contribute to OCD. Conversely, antidepressants that primarily affect other neurotransmitters typically
show no benefit in treating OCD.

Another area of research has identified abnormal functioning in specific brain regions associated with
OCD: the orbital region of the frontal cortex and the caudate nuclei within the basal ganglia. These
regions form a circuit involved in processing sensory information and translating it into thoughts and
actions. The orbital region generates impulses, which are filtered by the caudate nuclei before reaching
the thalamus, influencing subsequent thoughts and behaviors. Dysfunction in either of these regions may
lead to intrusive thoughts and compulsive behaviors characteristic of OCD.

Environmental Factors

Environmental stressors, such as trauma, abuse, or significant life events, may trigger or exacerbate OCD
symptoms in susceptible individuals. Stress can affect neurotransmitter levels and brain function,
potentially worsening OCD symptoms.
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PATIENT 22.
NAME_________________________________DATE_________________________
YALE-BROWN OBSESSIVE COMPULSIVE SCALE (Y-BOCS)*

Questions 1 to 5 are about your obsessive thoughts

Obsessions are unwanted ideas, images or impulses that intrude on thinking against your wishes and efforts to resist
them. They usually involve themes of harm, risk and danger. Common obsessions are excessive fears of
contamination; recurring doubts about danger, extreme concern with order, symmetry, or exactness; fear of losing
important things.

Please answer each question by circling the appropriate number.

1. TIME OCCUPIED BY OBSESSIVE THOUGHTS SCORE __________

How much of your time is occupied by obsessive thoughts?
0 = None
1 = Less than 1 hr/day or occasional occurrence
2 = 1 to 3 hrs/day or frequent
3 = Greater than 3 and up to 8 hrs/day or very frequent occurrence
4 = Greater than 8 hrs/day or nearly constant occurrence

2. INTERFERENCE DUE TO OBSESSIVE THOUGHTS SCORE __________

How much do your obsessive thoughts interfere with your work, school, social, or other important role
functioning? Is there anything that you don’t do because of them?
0 = None
1 = Slight interference with social or other activities, but overall performance not
impaired
2 = Definite interference with social or occupational performance,
but still manageable
3 = Causes substantial impairment in social or occupational performance
4 = Incapacitating

3. DISTRESS ASSOCIATED WITH OBSESSIVE THOUGHTS SCORE __________

How much distress do your obsessive thoughts cause you?
0 = None
1 = Not too disturbing
2 = Disturbing, but still manageable
3 = Very disturbing
4 = Near constant and disabling distress

4. RESISTANCE AGAINST OBSESSIONS SCORE __________

How much of an effort do you make to resist the obsessive thoughts? How often do you try to disregard or
turn your attention away from these thoughts as they enter your mind?
0 = Try to resist all the time
1 = Try to resist most of the time
2 = Make some effort to resist
3 = Yield to all obsessions without attempting to control them, but with some
reluctance
4 = Completely and willingly yield to all obsessions
 23.
5. DEGREE OF CONTROL OVER OBSESSIVE THOUGHTS SCORE __________
How much control do you have over your obsessive thoughts? How successful are you in stopping or diverting
your obsessive thinking? Can you dismiss them?
0 = Complete control
1 = Usually able to stop or divert obsessions with some effort and concentration
2 = Sometimes able to stop or divert obsessions
3 = Rarely successful in stopping or dismissing obsessions, can only divert attention
with difficulty
4 = Obsessions are completely involuntary, rarely able to even momentarily alter
obsessive thinking.

The next several questions are about your compulsive behaviors.

Compulsions are urges that people have to do something to lessen feelings of anxiety or other discomfort. Often
they do repetitive, purposeful, intentional behaviors called rituals. The behavior itself may seem appropriate but it
becomes a ritual when done to excess. Washing, checking, repeating, straightening, hoarding and many other
behaviors can be rituals. Some rituals are mental. For example, thinking or saying things over and over under your
breath.

6. TIME SPENT PERFORMING COMPULSIVE BEHAVIORS SCORE __________

How much time do you spend performing compulsive behaviors? How much longer than most people does it
take to complete routine activities because of your rituals? How frequently do you do rituals?

0 = None
1 = Less than 1 hr/day or occasional performance of compulsive behaviors
2 = From 1 to 3 hrs/day, or frequent performance of compulsive behaviors
3 = More than 3 and up to 8 hrs/day, or very frequent performance of compulsive
behaviors
4 = More than 8 hrs/day, or near constant performance of compulsive behaviors
(too numerous to count)

7. INTERFERENCE DUE TO COMPULSIVE BEHAVIORS SCORE __________

How much do your compulsive behaviors interfere with your work, school, social, or other important role
functioning? Is there anything that you don’t do because of the compulsions?
0 = None
1 = Slight interference with social or other activities, but overall performance
not impaired
2 = Definite interference with social or occupational performance, but still
manageable
3 = Causes substantial impairment in social or occupational performance
4 = Incapacitating
 24.
8. DISTRESS ASSOCIATED WITH COMPULSIVE BEHAVIOR SCORE __________
How would you feel if prevented from performing your compulsion(s)? How anxious would you become?
0 = None
1 = Only slightly anxious if compulsions prevented
2 = Anxiety would mount but remain manageable if compulsions prevented
3 = Prominent and very disturbing increase in anxiety if compulsions interrupted
4 = Incapacitating anxiety from any intervention aimed at modifying activity

9. RESISTANCE AGAINST COMPULSIONS SCORE __________

How much of an effort do you make to resist the compulsions?
0 = Always try to resist
1 = Try to resist most of the time
2 = Make some effort to resist
3 = Yield to almost all compulsions without attempting to control them, but with
some reluctance
4 = Completely and willingly yield to all compulsions

10. DEGREE OF CONTROL OVER COMPULSIVE BEHAVIOR SCORE __________

How strong is the drive to perform the compulsive behavior? How much control do you have over the
compulsions?
0 = Complete control
1 = Pressure to perform the behavior but usually able to exercise voluntary control
over it
2 = Strong pressure to perform behavior, can control it only with difficulty
3 = Very strong drive to perform behavior, must be carried to completion, can only
delay with difficulty
4 = Drive to perform behavior experienced as completely involuntary and over-
powering, rarely able to even momentarily delay activity.

TOTAL SCORE ______________

Use Exit button to go back Print this
Y-BOCS Symptom Checklist
Instructions: Generate a Target Symptoms List from the attached Y-BOCS Symptom Checklist by
asking the patient about specific obsessions and compulsions. Chock all that apply. Distinguish between
current and past symptoms. Mark principal symptoms with a "p". These will form the basis
of the Target Symptoms List. Items marked may “*” or may not be an OCD phenomena.
Current Past
AGGRESSIVE OBSESSIONS
Fear might harm self
Fear might harm others
Violent or horrific images
Fear of blurting out obscenities or insults
Fear of doing something else embarrassing*
Fear will act on unwanted impulses (e.g., to stab
friend)
Fear will steal things
Fear will harm others because not careful enough
(e.g. hit/run motor vehicle accident)
Fear will be responsible for something else terrible
happening (e.g., fire, burglary
Other:_______________________________
CONTAMINATION OBSESSIONS
Concerns or disgust w\ with bodily waste or
secretions (e.g., urine, feces, saliva Concern with dirt
or germs
Excessive concern with environmental contaminants
(e.g. asbestos, radiation toxic waste)
Excessive concern with household items (e.g.,
cleansers solvents)
Excessive concern with animals (e.g., insects)
Bothered by sticky substances or residues
Concerned will get ill because of contaminant
Concerned will get others ill by spreading contaminant
(Aggressive)
No concern with consequences of contamination
other than how it might feel
Other:
SEXUAL OBSESSIONS
Forbidden or perverse sexual thoughts. images. or
impulses
Content involves children or incest
Content involves homosexuality*
Sexual behavior towards others (Aggressive)*
Other:
HOARDING/SAVING OBSESSIONS
(distinguish from hobbies and concern with objects of monetary or
sentimental value)
RELIGIOUS OBSESSIONS (Scrupulosity)
Concerned with sacrilege and blasphemy
Excess concern with right/wrong, morality
Other:
OBSESSION WITH NEED FOR SYMMETRY OR EXACTNESS
Accompanied by magical thinking (e.g., concerned
that another will have accident dent unless less
things are in the right place)
Not accompanied by magical thinking
MISCELLANEOUS OBSESSIONS
Need to know or remember
Fear of saying certain things
Fear of not saying just the right thing
Fear of losing things
Intrusive (nonviolent) images
Intrusive nonsense sounds, words, or music
Bothered by certain sounds/noises*
Lucky/unlucky numbers
Colors with special significance
3 superstitious fears
Other:
Current Past
SOMATIC OBSESSIONS
Concern with illness or disease*
Excessive concern with body part or aspect of
Appearance (eg., dysmorphophobia)*
Other
CLEANING/WASHING COMPULSIONS
Excessive or ritualized handwashing
Excessive or ritualized showering, bathing,
toothbrushing grooming, or toilet routine Involves
cleaning of household items or other inanimate objects
Other measures to prevent or remove contact with
contaminants
Other
CHECKING COMPULSIONS
Checking locks, stove, appliances etc.
Checking that did rot/will not harm others
Checking that did not/will not harm self
Checking that nothing terrible did/will happen
Checking that did not make mistake
Checking tied to somatic obsessions
Other:
REPEATING RITUALS
Rereading or rewriting
Need to repeat routine activities jog, in/out door,
up/down from chair)
Other _____________________________
COUNTING COMPULSIONS
___________________________________
ORDERING/ARRANGING COMPULSIONS
___________________________________
HOARDING/COLLECTING COMPULSIONS
(distinguish from hobbies and concern with objects of monetary or
sentimental value (e.g., carefully reads junk mail, piles up old newspapers,
sorts through garbage, collects useless objects.)
___________________________________
MISCELLANEOUS COMPULSIONS
Mental rituals (other than checking/counting)
Excessive listmaking
Need to tell, ask, or confess
Need to touch, tap, or rub*
Rituals involving blinking or staring*
Measures (not checking) to prevent: harm to self -
harm to others terrible consequences
Ritualized eating behaviors*
Superstitious behaviors
Trichotillomania *
Other self-damaging or self-mutilating behaviors*
Other
Adapted from Goodman, W.K., Price, L.H., Rasmussen, S.A. et al.:
“The Yale-Brown Obsessive Compulsive Scale.”
Arch Gen Psychiatry 46:1006-1011,1989
 NovoPsych

Obsessive-Compulsive Inventory - Revised (OCI-R) (OCI-R)

Instructions:
The following statements refer to experiences that many people have in their everyday lives. Select the
option that best describes how much that experience has distressed or bothered you during the PAST
MONTH.

Not at all A little Moderately A lot Extremely

I have saved up so many things that they get in the

1
way.
0 1 2 3 4

2 I check things more often than necessary. 0 1 2 3 4

3 I get upset if objects are not arranged properly. 0 1 2 3 4

4 I feel compelled to count while I am doing things. 0 1 2 3 4

I find it difficult to touch an object when I know it has

5
been touched by strangers or certain people.
0 1 2 3 4

6 I find it difficult to control my own thoughts. 0 1 2 3 4

7 I collect things I don’t need. 0 1 2 3 4

8 I repeatedly check doors, windows, drawers, etc. 0 1 2 3 4

I get upset if others change the way I have arranged

9
things.
0 1 2 3 4

10 I feel I have to repeat certain numbers. 0 1 2 3 4

I sometimes have to wash or clean myself simply

11
because I feel contaminated.
0 1 2 3 4

I am upset by unpleasant thoughts that come into my

12
mind against my will.
0 1 2 3 4

I avoid throwing things away because I am afraid I

13
might need them later.
0 1 2 3 4

I repeatedly check gas and water taps and light

14
switches after turning them off.
0 1 2 3 4

15 I need things to be arranged in a particular way. 0 1 2 3 4

16 I feel that there are good and bad numbers. 0 1 2 3 4

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 NovoPsych

Not at all A little Moderately A lot Extremely

I wash my hands more often and longer than

17
necessary.
0 1 2 3 4

I frequently get nasty thoughts and have difficulty in

18
getting rid of them.
0 1 2 3 4

Developer Reference:
Foa, E. B., Huppert, J. D., Leiberg, S., Langner, R., Kichic, R., Hajcak, G., & Salkovskis, P. M. (2002). The
Obsessive-Complusive Inventory: Development and validation of a short version. Psychological Assessment,
14(4), 485–495. https://doi.org/10.1037//1040-3590.14.4.485

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