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ERP with cognitive bio-behavioral self treatment in blasphemous OCD: A Case

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Article · January 2016

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 Volume: 5: Issue-1: January-2016 ISSN:2278-0246

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ERP WITH COGNITIVE BIO-BEHAVIORAL SELF TREATMENT IN BLASPHEMOUS

OCD: A CASE REPORT

Vandana Choudhary1, Swarnali Bose2, Dr. Pawan Sharma3, Dr. Shree Ram Ghimire*4
1
PhD Scholar, Department of Psychiatry. All India Institute of Medical sciences (AIIMS), New Delhi
2
PhD Scholar, Ranchi University
3
Resident. Department of Psychiatry, All India Institute of Medical sciences (AIIMS), New Delhi
4
Consultant Psychiatrist, Transcultural Psycosocial Organization Nepal (TPO-Nepal), Kathmandu, Nepal
*Corresponding author: E-mail: srghimire@tponepal.org.np

ABSTRACT:
Patients with blasphemous obsessions and related compulsions often experience excessive guilt and consider
these thoughts to be equivalent to committing a sinful act against God. Though pharmacological management
helps in controlling severity of symptoms to some extent; but rarely addresses the associated cognition of self-
blame. Non-pharmacological management, especially Cognitive Behavior Therapy is considered as standard,
evidence-based therapy in such cases; however, its efficacy in scrupulous Obsessive compulsive disorder (OCD)
is limited. Cognitive Bio-behavioral Self Treatment (CBST) is a newly emerging therapy, but has hardly been
used with Exposure and Response Prevention (ERP) to address self-attributional errors. We present a case of a
23-year old male, suffering from blasphemous OCD and secondary guilt. He underwent ERP along with CBST,
which resulted in significant decrease in OC symptoms, decreased guilt by development of new insight which
lead to better control over his thoughts and behavior.

Keywords: Blasphemy, Obsessive compulsive Disorder, guilt, self-blame, Exposure and Response Prevention,
Cognitive Bio-behavioral self-treatment.

INTRODUCTION
OCD is recognized as one of the most common but treatable forms of mental disorder. Cognitive Behavioral
Therapy (CBT) is regarded as an effective and evidence based treatment protocol[1,2]. Blasphemous thoughts in
patients diagnosed with scrupulous obsessions present with excessive concern and guilt of committing sin against
religious or moral doctrine. Often such patients self-attribute themselves of being perverted,which further
perpetuates the guiltthat makes the psychological intervention difficult[3]. Various modificationsin the standard
protocols of psychological interventions have been reported[4].One such form of psychotherapy developed
specifically to handle the attributional errors using biological and cognitive awareness is “Cognitive Bio-
behavioral Self Treatment (CBST)”[5]. We present a case of ateacher and faith healer having extreme distress

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due to blasphemous nature of obsessions and following of elaborate rituals which had become disabling. He
received ERP delivered in combination with CBST that significantly improved the symptoms.

CASE REPORT
A 23 year old married male from a Muslim family teacher and faith healer by occupation, with no significant past
history of any psychiatric or medical illness, presented with chief complaints of repeated blasphemous
thoughtsand sexual images of Goddess. He would chant special prayers for long hours to get rid of these thoughts
and images and avoid various daily routine activities. He also complained of depressed mood and reduced sleep
for past 4 years as a result of these symptoms. There wasa progressive increase in intensity of symptoms over
time. Psychological assessment report indicated excessive self-doubt, difficulties in decision making and feelings
of anxiety and insecurity. There was a perceived sexual inadequacy, along with high moral strictures and
thoughts of need for self-punishment. Further, he seemed to have negative sense of self-worth and excessive
internalization of feelings which was usually dealt with using undoing, reaction formation and projection as
defense mechanisms.
On Yale Brown Obsessive Compulsive Scale (Y-BOCS) he had scores of 19 and 12, respectively in obsessions
and compulsions with a total of 31 indicating severe range of obsessive compulsive symptoms. Depressive
episode of moderate and major intensity was identified on Beck Depressive Inventory (BDI) and Hamilton
Rating Scale for Depression (HRSD) with the score of 16 and 24, respectively. Hamilton Rating Scale for
Anxiety (HRSA) also revealed severe range of anxiety with the score of 32. The symptoms had persisted with
minute fluctuations despite continuous pharmacological treatment. The patient was also on continuous non-
pharmacological treatment in the form of CBTchiefly using distraction techniques without ERP since past 4
months which led to some initial improvement, but the symptoms relapsed soon since past 1 month.
Based on the rationale that cognitive techniques immediately following by ERP sessions (especially with mental
compulsions) leads to improved therapeutic outcome[6,7], non-pharmacological treatment was again started. A
total of 18 sessions were taken where each session lasted for 45-50 minutes, held twice a week. The prime
objective of the therapy was tomodify specific cognitive processes and behaviors maintaining obsessive
compulsive symptoms. Thus, Psychoeducation and ERP (in vitro) were delivered, along with CBST immediately
following it.
Psychotherapy was delivered over the course of three distinct phases. In the first phase, patient was
psychoeducated in detail about the disorder, its etiology, prevalence, course and nature; thereby, highlighting the
importance of psychotherapy. Middle phase of psychotherapy was broadly divided into two parts. In the first part,
basic principles of CBST was introduced with the prime purpose of helping the patient relieve the stress of self-
blame by learning to recognize and “Re-label” all worries as obsessive thoughts and compulsive urges, without a
basis in reality. Thereafter, a process of “Re-attributing” the cause of obsessions and compulsions tothe
neurobiological condition of OCD,rather than calling them a product of the “self” was initiated. Thereby, patient
was introduced with the concept of “15-minutes delay rule”. He was, hence, made to practice postponement and
thereby, delayingthe intense urge to perform the mental rituals by 15-minutes; subsequently, even moretime till
the urge fades completely. During that postponement, patient was made to “Refocus” on other activities that were
more important or pleasant for that moment to perform. For example, he chose to listen to music by that time. As
a result, patient started “Revaluing” those thoughts and urges as less indicative of his mistakes and merely a false
alarm to actually performing it.
In the second part of the therapy, the rationale behind ERP was explained. As part of the homework assignment
thereafter, patient was asked to keep a record of his OC symptoms by maintaining a diary where a detailed record
of the type of symptoms, duration of its persistence, Subjective Unit of Distress Scale (SUDS) rating from 1- 100
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along with the safety behavior were recorded at various intervals during the day. Based on the detailed clinical
interview and subjective record of symptom behavior, anxiety hierarchy was constructed starting from least
anxiety producing symptoms (20% SUDS rating) to extreme anxiety producing symptom (100% SUDS rating),
and ERP was delivered for each such that patient successfully gained control over situation rated as ‘fear
provoking’. After each ERP session, revision of various CBST discussed previously, were reintroduced in order
to help patient understand the irrationality of thought. This subsequently helped in challenging the dysfunctional
assumption and distortion to immediately generate alternative explanations for the problem behavior. The
sessions, thus, yielded immediate insight and understanding over the irrationality of the thoughts and urges. One
of the greatest advantages in CBST was that the patient could practice the sessions himself at home which helped
him to gain confidence to be in better control of his own thoughts and behavior.
Following 18 sessions of ERP with CBST, there was significant improvement in his OC symptoms. At the end of
the final session, various pre-assessment tools were re-administered to monitor progress. On Y-BOCS, there was
a total score of 14, indicating mild range of obsessive compulsive symptoms, with a score of 9 on obsessions and
5 on compulsions. On BDI and HRSD, there was mild depression indicated by score of 11 and 12 respectively.
On HRSA, a score of 16 was obtained indicating mild range of anxiety symptoms.

DISCUSSION
The main aim of CBST in ERP is to help patient reduce excessive self-blame by understanding and monitoring
the real cause of illness, and relabeling it to acquire more adaptive skills involving alternative thought patterns.
Previous studies have revealed that patients having obsessions containing sexual thoughts is experienced as
intensely guilt provoking, yielding to even severe forms of compulsive rituals to reduce the self-blame[3].
Specifically, if the nature of sexual obsession involves blasphemous content, anxiety related to their religion
leads to a sense of self-blaming attitude for having a sinful thought, and hence, the resulting guilt worsens the
case. To counter this anxiety, patient often engages in performance of elaborative religious practices and rituals
to become compulsive[8]. Further, religious patients suffering from blasphemous thoughts often refuse ERP,
asthey experience such instructions as sinful. However, recent evidences support the view that cognitive therapy
can be used to increase adherence to ERP, especially with mental compulsions[1]. Further, CBST is a form of
recent cognitive therapy proposed to have a beneficial effect on patient’s self-esteem, as it gives a sense of
freedom by reducing self-blame and increasing thecontrol over obsessions and compulsions by patient’s
understanding of the process by which they empower themselves to fight OCD, and by clearly appreciating the
control one gains by training the mind to overcome compulsive or automatic responses to intrusive thoughts or
feelings[6].
To conclude, this case report demonstrates the efficacyof CBST along with ERP in specifically decreasing self-
blame among subjects with blasphemous nature of obsessions and compulsions which was not manageable with
pharmacotherapy or behavioral psychotherapy. Thus, there is a need to focus on practicing ERP with CBST in
patient with blasphemous nature of obsession and compulsions, to help them achieve a sense of freedom and
control over their own thoughts and behavior.

REFERENCES
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