CBT FOR PRIMARILY OBSESSIVE OCD

Amana II MPhil
Guide : Mr.Anirudh Rajan
Introduction-
OCD-
Obsessions are uncontrollable, recurrent and persistent thoughts, impulses, or images that are experienced at some time
during the disturbance , as intrusive and inappropriate, and cause marked anxiety or distress. Compulsions are behaviors
that the person feels the urge to repeat over and over in response to an obsession.

OCD can be characterized in individuals as

● Fear of contamination or dirt
● Doubting and having difficulty tolerating uncertainty
● Needing things orderly and symmetrically
● Aggressive or horrific thoughts about losing control and harming themselves or others
● Undesired or unwanted thoughts, including aggression, or sexual or religious subjects.
Obsession without Overt Compulsion-
Some researchers of OCD have commented on the disabling nature of this form of OCD- Obsession without
overt compulsion:
‘Obsessive thoughts’ (ruminations, temptations and doubts) are just as incapacitating as ‘Compulsive
behavior’ (rituals). ( Solyom, Ledwidge. & Solyom, 1986).

This specific form, obsessive thoughts without overt compulsions, was believed to be rare but a clinically
interesting variant of OCD that was highly resistant to treatment. Techniques like thought stopping have met
with inconsistent success at best. (Beech & Vaughn, 1978: Foa, Steketee. & Ozarow, 1985).

This form of OCD (no reported compulsions but obsessions only) was established to be as high as 50-60%
(Weismann et al., 1994). Pure obsessions were reported to be difficult to distinguish from other disorders
such as GAD, Hypochondriasis and some atypical forms of Agoraphobia.
Assessments-
The Yale-Brown Obsessive Compulsive Scale (Goodman et al., 1989) is a clinical rating scale including a symptom
checklist. It is widely used in recent therapy trials of cognitive, behavioral and pharmacological methods.

For general OCD and related symptoms, three self-report measures are also recommended.
1. The Padua Inventory (Sanavio, 1988) - a 60 item inventory of OC symptomatology with four subscales- Loss of
Mental Control, Contamination, Checking and Impulses and Worries about loss of control.
2. Beck Depression Inventory (Beck, Epstien, Brown, & Steer, 1988)
3. Beck Anxiety Inventory (Beck, Rush, Shaw, & Emery, 1979)
Self- Monitoring Diary-
Self- Monitoring Diary helps to measure discomfort associated with the thoughts, thought frequency, and total duration of
thoughts. (Kozak, Foa. & McCarthy, 1988; Marks, Hallam, Connolly, & Philpott, 1977). Since thought frequency and
thought duration may cause varied distress and discomfort in individuals and differ across subjects,

In recent studies the format of the scales have become more subjective rather than quantification of the number of
thoughts or the duration of thoughts.
COGNITIVE MODEL OF OBSESSIVE THOUGHTS-
The model is a synthesis of earlier cognitive behavior models (Rachman & Hodgson, 1980; Salkovskis, 1985) and
clinical and research experiences with obsessions without overt compulsions.

● OBSESSIONS
● APPRAISALS
● COGNITIVE RITUALS
● COPING STRATEGIES
● NEUTRALISATION
● RESPONSE PREVENTION and what should be trageted?
Obsessions-
Obsessions majorly refer to themes of aggression and loss of control, harming, negligence, dishonesty, accidents,
sexuality, religion, contamination and illness. There are some obsessions of minor ambiguities in everyday life as well.
Existential questions, and neutral thoughts can also come under obsessions.

Appraisal-
Appraisal is the process by which the individual attaches meaning to the thought in terms of its value, its importance, its
implications. If the thought is adequately appraised, the individual treats the thought as a cognitive event that does not
necessarily have any real life reference, the thought has little importance and no particular implications. No further
processing will take place and no action such as neutralization, assurance seeking or avoidance will happen. On the other
hand if the thought is not adequately appraised as having negative implications then further processing will occur.
An example of a negative appraisal would be-

A guy buys a lottery ticket, has an intrusive thought that he will win the lottery. Negative or inadequate appraisal
happens, he seriously plans life changes, quits his job and maxes out his credit card.
The three sources of information that direct appraisal are
Basic Assumptions- developed from previous learning history and experiences.

Distortions- consistent errors in the cognitive processing such as dichotomous thinking, responsibility omission bias and
emotional or ex-consequentia reasoning.

Temporary Assumptions- situationally determined and time- limited assumptions loosely structured.

The combination and dynamic interaction of these three directs the process of appraisal and will result in the intrusion
being perceived as threat.
DISTORTIONS
Dichotomous Thinking- Thinking in terms of binary. Black or white, good or bad, All or nothing kind of thoughts.

Responsibility Omission Bias- evaluating a decision to commit an action more negatively than a decision to omit an
action, given that both decisions have the same negative consequence. (Eg. Not taking the covid vaccine thinking it will
anyways not contain the spread of virus).

Emotional or Ex-Consequentia Reasoning- false alarms are not recognized and irrational beliefs are maintained. A
vicious cycle where thoughts of impending doom are validated to intensify distress. ( Eg. A woman walking down the
street thinks, she feels unsafe and the distress intensifies).
Some interpretations of obsessions observed in OCD patients without overt compulsions-
Cognitive Rituals and Coping Strategies-
Cognitive rituals are neutralized- voluntarily initiated activity which is intended have the effect of reducing the perceived
responsibility (Salkovskis, 1989) or coping mechanisms are used- actions to try simply to remove the thought or reduce
discomfort (Rachman, 1989). Cognitive rituals play the same role as overt rituals.

Individuals different strategies to respond to intrusive thoughts-

● They do nothing
● Some form of self assurance
● Analyzing the thought through
● Seeking reassurance
● Replacing the thought with another one
● Performing a cognitive action to remove the thought by distracting and thought stopping.
Neutralization-
Anything that is voluntary and effortful directed at removing, preventing, or attenuating the thought or the associated
discomfort, or which attempts to change the thought’s meaning.
Basically when a person mentally replaces unwanted, unpleasant thoughts or images with pleasant or more neutral ones.
(Eg.A woman tries to imagine her child sitting in a field of flowers after having a thought about her getting kidnapped
from the playground at daycare).
Response Prevention- What should be targeted?
Identifying neutralizing strategies is the first step. Comprehensive behavioural analysis, using semi structured interviews
can be used. Self monitoring can help increase awareness of neutralizing responses.
Directing the individual to internal states such as guilt and anxiety can help identify neutralizing responses which seem
automatic but are fundamentally voluntary.
Avoidant responses maintain the anxiety state while adaptive responses deal with the threat along with the anxiety.

Response prevention of all neutralizing strategies will minimize the chances of a particularly undesirable situation rising.
Adequate responses (appraisal, exposure, response prevention) are emitted under low-moderate anxiety but inadequate
responses (inadequate appraisals, neutralization ) still occur under high anxiety conditions.
Role of Mood-
Mood plays a modulating role in OCD. negative mood states increase frequency and duration of obsessions, increase
likelihood inadequate appraisals with inflated subjective probabilities, extreme consequences and decrease likelihood of
adequate appraisals.
They also decrease the efficacy of neutralization and increase hypervigilance for triggering stimuli.
They also play a role in decreasing motivation to engage in strategies learnt during therapy.
What is ERP?
The treatment characteristics of ERP is to change the patient’s understanding of obsessions, prevent neutralization and
thus enable patients to habituate to the obsessive thoughts.
Objectives include
1. To provide an explanation of obsessions
2. To enable the patients to understand the role of neutralization in the maintenance of obsessive thoughts.
3. To prepare the clients for exposure to thoughts to the situations which trigger the obsessions.
4. To correct the overestimation of the importance of thoughts when necessary
5. To help clients learn response prevention.
6. To correct the exaggeration of specific feared consequences in response to a thought.
7. To correct exaggerated responsibility and perfectionism.
8. To make the patient aware of situations in which they are vulnerable.
9. To prepare them to use strategies when relapse occurs.
According to the individual characteristics of the clients the treatment is planned (the type of exposure, the
targets for response prevention)
Therapist Attitudes
● Therapists should show confidence in the treatment without underestimating the difficulties involved for the client.
● The therapist should have a mindset of collaboration and working together.
● The therapist needs to emphasize the specific parts of therapy to help the patient understand the treatment plan
comprehensively since they could have been to various MHPs already.
● Socratic dialogue should be encouraged to learn of the patient's experiences.
● Empathy and appropriate response without being diverted from goals should be priority for therapists.
● Therapists must build trust but must remain firm. At the same time they must be ready to confront the patient when
exposure goals previously established mutually are not respected.
● When working with patients who have perfectionism, it is important to note that the therapists should have a
flexible attitude.
● Coping model instead of a Mastery model is to be used in such cases.
Self Monitoring-
Assessment can take 2-3 sessions. YBOCS maybe useful with BAI, BDI and Padua inventory can be given as homework
tasks to get an idea of principal and associated symptoms.

Once target symptoms are identified, Self monitoring should be introduced. Any apprehensions, the patients have that self
monitoring may increase obsessions should be addressed and made clear that self monitoring help is good for them.

Self monitoring helps in identifying symptom severity, modulating the variability and eventually in relapse prevention.
First Intervention-

In all sessions the therapist first sets the agenda for the session and verifies self monitoring and other assignments given
to the patient. Reflecting on the homework and following up leads helps patients understand the importance of
homeworks.
The goals for the first session are
1. To establish therapeutic contract
2. To provide a model for obsessive thoughts that will be used throughout the treatment.
Establishing Therapeutic Contract-
● The therapist states the explanation for each step of treatment and responds to all valid questions of the patient.
The goal of each exercise is well explained and identified by both parties. Patients are actively involved in each
decision of the treatment process. They can give personally relevant ideas to the therapist in terms of setting
homeworks.
● The therapist will never force the client but remind them of the contract whenever the patient loses will or track of
the treatment. The therapist also seeks feedback from the patient actively.
● The patient holds responsibility to report whether the exercises have been accomplished or not to understand
challenges faced by clients and to make adjustments.

The model that is presented to is adapted according to the patient’s sophistication. In all cases the patient's own
obsessions, appraisals, beliefs, neutralization strategies etc are illustrated in the model.
Intrusive Thoughts-
● The first step is to provide an account of intrusive thoughts. Unpleasant thoughts come to 99% of the population.
They may include various themes.
● The therapist gives the patient a list of thoughts reported by the general population and invites the patient to read
the list.
● The point is to make the client understand that the content does not differ for patients and thoughts reported by the
general population.
● Few differences like the frequency of thoughts, the discomfort, the duration , the importance the person attaches to
the thoughts exist.
● Strange intrusive thoughts are common in most people but when they turn problematic are then called obsessions.
● The goal is to change the reactions to the thoughts by changing the importance that you attach to the thoughts, to
change the perception. Eventually the duration of the thoughts will reduce, with the frequency and eventually the
discomfort will reduce.
Appraisal
Appraisal is the importance given to the thoughts. The upset and discomfort caused by the thought is an effect of how the
person attaches to the thought. There may be several interpretations given to a thought at any given time.
Examples-
- Thinking about this means it’s true.
- If I think about something and don't do anything, I will be responsible if it happens.
- Having this thought means that I am not like other people.

Confronting the thought is not the priority but to point out that some interpretations deal with the thought’s presence and
whereas others are more based on the thought’s content. Both the two interpretations can be upsetting.
Neutralization-
The next step in the model is the make the patient aware of the idea of neutralization-

● If the person feels the thought is negative, dangerous, unacceptable etc, it is normal to want to remove the thought,
resolve it in one way or another.
● Keeping the thought away is impossible.
● All efforts to control, remove or avoid the thoughts come under neutralization.
● Asking the patient questions like, How many different strategies have you tried? How many have worked? How
many worked at first but worked less over time? How many work all the time? How many work sometimes? gives
an idea of the neutralization ideas applied by the patient pre treatment.
The Basic Model-
● The client is made aware about obsessions, neutralization, how it is futile to think that neutralization will help
solve the problem.
● The thought popping up in the head is involuntary but the importance attached and neutralization is voluntary even
though they may seem automatic. (ELEPHANT SITUATION)
● The patient is taught to distinguish the voluntary and involuntary parts in the thought processing.
Just like moving from manual to automatic cars, some effort to process thoughts in a new way can be established.
Similar to changing gears in a manual car, it becomes an automatic habit overtime but is
voluntary.
Summary-
1. Unpleasant thoughts are normally experienced by almost anyone. They can be involuntary and unwanted. They
can disturb some more than others.
2. People who are troubled by the thoughts interpret them in ways and attach a great deal of importance to the
thoughts presence or content.
3. Neutralization then comes as a natural reaction to deal with the discomforting and unpleasant thought.
4. Attempts to suppress or remove the thought result in return of the thought.
5. The goal of therapy is to change the importance given to the thoughts and the strategies used when the thought
occurs, and thus decrease the distress caused by the thought, its frequency and duration
Second and Third Intervention-
The goal of second treatment session is to check that the model is understood and to prepare the patient for exposure and
response prevention. Any personalization of the treatment process according to the patient can also be done.
The Role of Anxiety-
Anxiety plays a major role in maintaining the thoughts. The patients are educated to name the emotions they go through
concerning thoughts; discomfort, frustration, stress, sadness, guilt etc.

When the thought is given importance in terms of danger or threat, anxiety may increase. It is normal for people to do
something with the thought to reduce anxiety. Neutralization if working , provides a short term solution and acts as a
negative reinforcement. But overall the anxiety worsens and frequency of the thought also increases.
Neutralization means the thought will come back and the importance given to the thought is increased. The sense of
losing control along with the anxiety may increase with each subsequent emotion.
The Role of Magical Thinking-

Magical thinking occurs when a patient firmly believes neutralization can stop a negative consequence from occurring
even if there is no realistic causal link between action and feared event.. It is important to challenge this distortion before
exposure can be initiated. When the feared event eventually does not happen, the neutralization idea gets reinforced even
though nothing would have happened otherwise as well. This also increases the chances of the client neutralizing further.

Eg. Locking the house and checking the lock 3 times will keep the house safe.
Avoidance-
Some patients use passive avoidance instead of neutralization to handle the distressing thought. Avoidance, by adding
importance attached to the thought, maintains obsessions by increasing the range of potential stimuli, maintaining the
importance given to the thoughts, and by preventing the patient from learning that anxiety provoked by the thoughts or by
the stimuli will decrease even when the stimulus is confronted.

Avoidance is basically another form of neutralization. In this case, it is not doing something that enables you to either
limit the frequency of the thoughts or limit the importance that you attached to the thought by avoiding certain types of
triggers. These triggers can be people (children), place (train), objects(screw driver) , information( reading about a
particular illness) , internal sensations or emotional states(anger) or other thoughts (someone doing suicide). Avoiding
triggers make the patients give them more and more importance and leads to increased scanning of environment for
potential triggers.
Reassurance Seeking-
It is also another form of neutralization. It works by temporarily changing the importance that you attach to the thought.
It may work for the short term but not in the long term. Reassurance is specific to time and situation. It may lose
effectiveness if there is a doubt regarding the adequacy of the description of the situation. Furthermore increases
attention given to the thought and increases over time. Seeking reassurance from other person takes away the ability to
reflect and observe thoughts and learnt to handle the anxiety and thoughts.
Eg.
● asking if someone is mad at you.
● asking someone to promise that you'll be safe or OK.
● asking someone whether you did the right thing or made the right decision.
Exposure-
The patient, after fully understanding the model, is taught to break the vicious cycle and tolerate the thought. This
involves deliberately thinking about the thought and not voluntarily neutralizing. Anxiety will then decrease, importance
given to the thought will decrease, feared consequences that may happen or may not happen may be open mindedly
observed. Eventually the thoughts will decrease in their frequency,intensity and duration.

The idea of progressive exposure is then introduced.

● Obsessions can be given analogy to the phobia of one's own ideas. And the same method of treatment can be used
to progressively confront thoughts and anxiety at each level.

● Exposure is presented as a process where simple steps will be mastered before moving to more difficult situations
and thoughts. The therapist helps the patient understand the logic behind exposure. The first exposure thought will
be the smallest most manageable thought available.
If the total exposure is climbing 100 stairs. When the person is at the bottom, 100 stairs can be too much to tackle at once.
But the person can probably climb 10 stairs. After reaching the 10th stair, the person can stay for a while and climb till
the 20th stair. In bursts of 10 stairs, the 100th stair can be reached in 10 stages. When the person has reached the 90th
stair, the difficulty of what remains to be confronted wil be pretty much the same as what you will already have succeed 9
times before.
Identifying beliefs or expectations about the consequences of high levels of anxiety that may be encountered during
subsequent exposure. Comorbidities are also to be screened prior to the treatment. Relationship with anxiety is assessed
and made functional before getting into exposure. Clear understanding is established about how exposure will be
conducted.

The thoughts are presented on tape and it enables the therapist and the patients to repeatedly practice response
prevention. Tape loops are not really essential but provide practical and effective means of exposure and response
prevention.

Before starting exposure and response prevention, the idea of neutralization is revised with emphasis on the functions of
the strategy and not the form of the strategy. When there are several thoughts, the least anxiety provoking thought may be
targeted first.
Hierarchy for thoughts according to the anxiety levels

Hierarchy for multiple/different thoughts-

Anxiety Level Thought

2 Shouting out rude words

3 Pushing someone when walking in the streets

5 Punching someone in the face

7 Attacking someone with a knife

8 Going completely crazy, going on a rampage and killing a lot of

people
The text for exposure to the second thought in the hierarchy- PUSHING SOMEONE WALKING DOWN THE
STREET would be,
I am walking down the street, I see an old woman coming towards me. She looks frail and defenceless. All off a sudden I
have the thought, “What happens if I lose control and push her?” My stomach tightens, my hands sweat and I have
trouble breathing. The old woman is much closer. My fists clench and I struggle to keep control. She is almost up to me
and I start to panic. She is quickly past me and I keep on walking. I wonder if I did push her. The doubt starts to grow. I
see her lying in the streets with broken bones. The ambulance comes.
For obsessions regarding one major thought, the context of exposure will vary and it is not possible to have variety of
exposure targets arranged hierarchically in terms of the content. An example of a parent who has obsessions of stabbing
her child is discussed in the next table.
Hierarchy for a single thought-

Anxiety level Thought

3 WIth therapist in the office

4 With therapist in the office with a knife and picture of child

5 With therapist at home

6 Alone at home

7 At home with child and husband

8 Alone at home while child is there

The Use of a recorder wiil facilitate exposure in specific physical concepts

Preparing the Text-
The first target is mutually identified by both parties and the patient is made to describe the thought in detail. Questioning
is done until specific details are found. All the senses are brought into picture and the patient is asked to write the thought
down in detail. It is necessary for the patients to expose themselves as far as the feared consequence might go. Eg. getting
arrested for having a violent thought.

The therapist makes sure no neutralizing elements are included in the thought description. The therapist reads out the
thought to the patient to ask them if anything is missed out. Finally the thought is read out with sufficient expression and
leaving pauses for the image to be formed when hearing it. The therapist should be able to experience what it is like to
have the thought.
Exposure Exercise-
Instructions are given to listen to the recording and to stay with the thought. Not to block it, filter it or remove it (to avoid
neutralization). The levels of discomfort are closely monitored (typically self monitor).
The anxiety levels are measured through a self monitoring form, at the current level, the expected maximum level during
exposure and the expected anxiety level after the exposure. A graph can be made to track anxiety levels during the
exposure sessions.

If anxiety levels do not rise during the initial few minutes, The reasons can be that the recording does not contain words
that represent the actual thought or there is no sufficient time to form images using the words.
In such a case, other forms of exposure can be used.
The patient can be neutralizing where they anticipate negative consequences.
There is also chance of Cognitive avoidance.

For eg. a mother has the thought of using the curling heat rod to burn the child . The scenario finished with her
committing suicide. She used following forms of cognitive avoidance one after the other.

1.The electric cord of the curler was too short (preventing her from taking the curler far from the charging point).

2.She sat down holding the curler in her hand. (Feeling more in control).

3.Nothing happened when she held the curler against her son’s hands.(Even though it was plugged in and switched on).

4.She could feel the heat of the curler when she held it in her hands but nothing happened when she kept it against her
son’s hands.

Each of these departures were addressed in turn and rephrased as avoidance.

The exposure continues while the therapist observes for any physical changes and any discrepancies in physical changes
and verbal changes if any.

Afterwards, the current anxiety and maximum anxiety during the exposure is measured. Neutralization, if occurred, is
also identified. If it did, the form of neutralization and if the patient re-exposed to thought is clarified.

The therapist can look for challenges faced by patients and inform them that it is normal to find it difficult for the first
time before mastering exposure. Breaking a habit existing for years can be tough and practicing can make it less effortful.
Exposure after 2 sessions in the office is continued at home. The recording can be listened to once or twice a day for 5 to
6 days in a week. This can help avoid dichotomous thinking of having to think of the weeks objective as unattainable if
missed a day.
Later Exposure Sessions-
The exposure self monitor forms are examined at the start of each session.
The following instruction is used for exposure-
When thoughts occur, just watch them. See them come and watch them go without reacting to them; just leave them
where they are without trying to do anything in particular.
4 main ways are used to increase capacity of the stimulus thought to provoke anxiety.
1. Vary the stimulus- New elements are integrated in the tape and new fews discovered are addressed.
2. Vary the situation- The patient listens to the casette in various situations which trigger the thought or increase the
thoughts’ salience. Situations which provoke anxiety can be used in appropriate heirarchy.
3. Vary the intensity of the thought- anything that adds meaning of the thought is used as additional support.
4. Vary the mood state- by direct manipulation or by verbal induction

Exposure practices should gradually be faded out as distress, frequency and distress decreases with naturally occurring
thoughts and the patient is able to implement response prevention strategies.
Overview of Cognitive Correction-

1.Overestimating the importance of thoughts and its derivatives such as distorted cartesian thinking, fusion of thought
and action, and magical thinking.
2. Exaggerated responsibility for events beyond the control of the individual and the consequences of being responsible
for harmful events.
3. Need to seek a perfect state like perfect control over thought.
4. Overestimation of the probability and the severity of the consequences of negative events.
5. Beliefs that anxiety is caused by the thoughts is unacceptable and/or dangerous
Assessments-

The Padua Inventory (Sanavio, 1988) - a 60 item

inventory of OC symptomatology with four
subscales- Loss of Mental Control,
Contamination, Checking and Impulses and
Worries about loss of control.

The first page of the inventory is given to the

right.
.
The Structured interview on neutralization
assesses the neutralization patterns of the patient.
Cognitive intrusions questionnaire
Beliefs inventory