Cognitive Behavioural Therapy for Obsessive Compulsive Disorder

This in the sixth in a series of blog posts about CBT formulations. This blog will focus on CBT formulation for obsessive-compulsive disorder (OCD)

1. What is obsessive-compulsive disorder (OCD)?

OCD is the reoccurrence of intrusive thoughts combined with compulsive behaviours to reduce the anxiety experienced by such thoughts. For example, excessive hand washing due to fears of contamination. In order to meet formal diagnostic criteria for an OCD diagnosis, this preoccupation or compulsion must be present for a minimum of 2 weeks for most days. The distress must cause significant impairment in social, academic, occupational/education or other areas of functioning. Engagement in compulsions must be time consuming.

Some people may be more vulnerable than others to developing these difficulties.

2. Predisposing factors

Predisposing factors may include: early exposure to stressful situations, perfectionistic traits, low self-esteem, a tendency towards over-responsibility or the experience of abuse/trauma. The experience of parents with high moral standards may also predispose some individuals to developing OCD.

3. Core beliefs

Core beliefs may include the belief that thoughts are powerful and represent reality. This leads the individual to belief that they will be responsible if something happens (e.g. if they have a thought that someone gets hit by a bus, it will be their fault if this ever happens.  “My thoughts are powerful. I must not think bad things”.

4. Precipitating factors

Precipitating factors include stress or head injuries.

5. Perpetuating factors

Perpetuating factors include the engagement in compulsive behaviours, which reinforces the belief that this is what is neutralizing their thoughts and keeping everyone safe. Other perpetuating factors include having family members with OCD or loved ones who struggle to challenge intrusive thoughts and compulsive behaviours as this inadvertently reinforces them.

6. Protective factors

Protective factors include: high self-esteem, interests in engaging in activities, support from family and friends, adaptive coping strategies and insight into the likelihood that their intrusive thoughts are not representative of reality.

7. Case Example

Sally’s friend informs her she is going on a trip to Paris for work for a week. Sally immediately experiences intrusive images and thoughts of the plane crashing. Sally feels anxious and guilty about these images but the more she tries to block them the more frequent the images become. Sally begins to engaging in various rituals to reduce this anxiety, which she believes will keep her friend safe. Sally’s friend has a safe trip to Paris. Sally is relieved and associates this positive outcome with the compulsive behaviours/rituals she engaged in.

This can be understood within a CBT formulation as follows:

Predisposing factor: Not specified.

Precipitating factor: Sally’s best friend has to go on a work trip to Paris for the weekend. Sally experiences an intrusive thought that the plane would crash on the way to Paris. Sally becomes anxious at this thought and cannot stop thinking about it.

Perpetuating factors: Sally’s intrusive thought did not become a reality. Sally attributes this to her engagement in counting rituals. If Sally had not engaged in this ritual she would have observed that her intrusive thought was not a prediction for the future/magical thinking. This would also lessen her need to engage in counting or other rituals, as she would lessen her belief that she needs to do these to neutralize her intrusive images.

Protective factors: Unknown. Support from loved ones to challenge these rituals would help. If Sally were to engage in CBT this would help her to reduce her anxiety in more helpful ways.

The International Psychology Clinic

The International Psychology Clinic