Psychological Explanations of OCD Flashcards
Explain the Behavioural explanation of OCD
The principles of classical and operant conditioning has been applied to OCD and is based on the two-process model proposed by Mower.
a) Fear of a specific stimulus is acquired through the process of classical conditioning. This occurs when a neutral stimuli becomes associated with threatening thoughts or experiences through classical conditioning. This leads to anxiety. For example, touching a doorknob or shaking hands may become associated with the anxiety-provoking idea of contamination.
b) Compulsions are maintained by operant conditioning. When the individual learns that anxiety can be reduced by performing certain behaviours, this leads to repetition of these behaviours. For example, anxiety surrounding contamination can be reduced by hand washing. Reduction in anxiety is a powerful reinforcer for hand washing and therefore makes repetition of that behaviour much more likely. Social learning is another explanation. This suggests we learn ritualistic behaviour through imitation of models.
Evaluate the behavioural explanation of OCD - part one
The idea that patients with OCD produce compulsive rituals because tese rituals reduce anxiety makes sense (i.e. has face validity) and is supported by research evidence. Rachman - exposed patients with OCD to situations triggering their obsessions e.g. shaking hands if they had an obsession with contamination). As predicted, this produced a high level of anxiety. Howerver when the patients performed their compulsive rituals e.g. hand washing when exposed to such situations, their level of anxiety rapidly decreased. However, this doesn’t explain why the obsession was triggered in the first place. This is problematic for the behavioural explanation as it doesn not offer a complete explanation of OCD.
Evaluate the behavioural explanation of OCD - part two
Effective behavioural therapy - There is evidence for the success of Exposure and Response prevention therapy e.g. outcome studies such as Eddy - whose meta analysis of 15 clinical trials found nearly 70% out of 705 patients improved with ERP. This indicated that ERP is a highly effective therapy for many with OCD, but cannot account for the 30% who were not helped by behavioural therapy. However there are problems associated with assessing the effectiveness of treatments including that of reliable diagnosis of a condition which doesn’t have clear test results. In addition many OCD patients receive more than one treatment. For example, most diagnosed patients will be prescribed anti-anxiety drugs in addition to psychological therapy. A further problem for the behavioural explanation is that it’s hard to explain why for a few severely affected patients behavioural therapies are more effective after psycho-surgery.
Evaluate the behavioural explanation of OCD - part three
i) they fail to take account of genetic factors known to be involved in OCD; the fact that first degree relatives of OCD sufferers are themselves more likely to develop OCD than the general population is generally taken as evidence for a genetic explanation for OCD. However, imitation of the behaviour could also play a part. This is an example of the nature/nurture debate which asks how far behaviour can be attributed to biological factors (nature) and how far learning (nurture). In fact it is generally acknowledged that an interactionist approach is likely to provide a better explanation. An example of this for OCD would be the diathesis stress model. This suggests some individuals have a biological vulnerability for OCD but environmental triggers are needed for the disorder to develop. An individual with a high vulnerability may develop the disorder with limited triggers, while another person with low vulnerability is very unlikely to develop it, even under extreme stress.
ii) Although the behavioural approach was very dominant in the 1950s and 1960s, it’s reliance on animal research is not criticised. for example, research into avoidance learning used dogs and drew parallels with OCD patients who carry out rituals to prevent something bad happening. Solomon & Wynne - placed fogs in a box. A light came on and 10 sec later the dog received a shock unless it had jumped into another compartment. They carried on jumping, even after the shock was turned off. In the same way OCD patients carry on with their compulsive behaviour even though they know it is illogical. This somewhat simplistic parallel between animal and human behaviour is applied much less today.
Explain ERP - Exposure and Response Prevention
The most commonly used psychological therapy for OCD is ERP and was first developed by Meyer. This involves exposing patients to situation evoking obsessional distress until their anxiety levels decrease. At the same time, patients are instructed to resist performing the rituals they would typically use to reduce anxiety (i.e. response prevention). The combination of exposure to anxiety-evoking situations and response prevention eventually leads to extinction of the fear response. There are a number of steps the therapist will take in ERP:
a) Therapist assesses client’s obsessional thoughts and compulsive impulses e.g. contamination and cleaning).
b) client discusses their worst case scenarios (e.g. not cleaning, contaminating someone and causing illness)
c) Therapist outlines the therapy, emphasising the ultimate reduction in stress
d) Therapist takes the client through a hierarchy of distressing stimuli
e) This begins with moderately distressing situations so that it is relatively easy for the client to cope with their distress (e.g. touching a door). After they have coped successfully with such situations, more distressing ones will be introduced and so on (e.g. touching a toilet seat)
f) At all stages, patients are strongly encouraged to resist the temptation to perform their ritual compulsions (e.g. washing hands).
g) At the end of each treatment session the therapist tells the client to practice exposure for several hours before the next session
h) Outcome is assessed based on the extinction of learned fear responses
A client is usually offered 15-20, 1-2 hour sessions
Evaluate ERP in terms of effectiveness
There is strong evidence that ERP is effective to OCD. It seems that between 55-85% of OCD clients improve significantly with ERP and the therapeutic effects seem to be long lasting. Eddy et al - performed a meta analysis and found ERP to be more effective than cognitive based therapies. However ERP doesn’t benefit all clients. About 25-30% of clients who begin ERP drop out, mostly because of high levels of anxiety created created in in the therapeutic situation. Among those who remain in treatment, another 20% or more fail to derive any benefit. These figures indicate that approximately 50% of client’s are not significantly improved by ERP.
Its focus on eliminating the symptoms of OCD has been criticised as being very limited. The concept o cure for behaviourists involves changes in observable behaviour. This does provide clients with the skills needed to deal with their symptoms, but Psychodynamic theorists claim that failure to consider the underlying causes of mental illness leads to the danger of symptom substitution in the future whereby one symptom may be replaced by another.
there is also the issue of whether behaviour therapies generalise to real life or whether they produce any worthwhile lasting effects. The application of behavioural therapy may serve to produce the desired behaviour in the therapist’s room. However, it does not necessarily follow that the same behaviour will be produced in other situations.
Abramowitz - identified three factors influencing the effectiveness of ERP:
a) the beneficial effects were greater when the therapist, rather than the client, controlled the exposure situations.
b) the effects are greater when response prevention is total rather than partial. This is more likely to lead to extinction of the fear response.
c) It is especially effective for those suffering mostly from compulsions because the emphasis is on changing behaviour. Those who suffer mainly from obsessions sometimes benefit from having drug therapy in additions to ERP.
Evaluate ERP in terms of appropriateness
In general, ERP is an appropriate form of therapy for OCD. Most clients are very concerned about the numerous compulsive rituals they perform almost every day, and this therapy focuses directly on these rituals. More specifically, response prevention shows clients that no dire consequences follow if they fail to perform their usual rituals. In addition, ERP demonstrates to clients that it is possible to control and reduce the anxiety they experience when confronting distressing situations. Some researchers and therapists see behavioural therapies for OCD as dehumanising. They represent an overly simplistic and mechanical view of people and claim that we are not in control of our own behaviour. Behavioural techniques can, however , provide people with the means to achieve goals and by understanding the ways in which behaviours are learned and maintained, give them more self-control than they had before. This therapy take a relatively short time (compared to psychodynamic treatments) and does not have side effects (unlike biological treatments).
However, there are some ways in which ERP for OCD can be regarded as inappropriate:
a) the therapy is designed deliberately to create high levels of anxiety. This makes it unsuitable for some clients with OCD e.g. those with suicidal thoughts.
b) the high levels of anxiety created in ERP leads to a high dropout rate, with such clients not deriving much benefit from the therapy. However, drop out rates can be improved with the use of drug therapy.
c) It can be argued that creating high levels of anxiety in vulnerable clients is unethical. Clients do give informed consent to the therapy, but sometimes they underestimate how unpleasant the therapy will be. This means it is not suitable for all clients and drug therapies may be preferable.
d) ERP focuses more on compulsions than obsessions, suggesting that this form of therapy may be less appropriate for clients whose symptoms consist mainly of obsessions. Rachman - found clients who mostly have obsession are often not treated successfully by ERP.
Explain the cognitive explanation for OCD
the cognitive view sees OCD as a product of faulty and irrational thinking. People with OCD do not seem able to dismiss these involuntary and intrusive thoughts and blame themselves for having them and the terrible things that will happen as a consequence of these thoughts. In order to try to ward off the awful consequences (e.g. causing illness/death) people with OCD attempt to neutralise their thoughts (e.g. about contamination) through the methods of actions or thought suppression.
a) Actions to neutralise intrusive thoughts - Neutralising intrusive thoughts usually involves carrying out actions that are intended to reduce any potential threats. For example, repeated hand washing will neutralise intrusive thoughts about contamination. These neutralising acts bring about temporary relief in anxiety and so as a reinforcement. reinforced behaviour are then repeated and a pattern of repetitive, ritualistic behaviour begins.
b) Suppression to neutralise intrusive thoughts - People with OCD may attempt to suppress their obsessional thoughts. However, this is likely to make them more preoccupied with the irrational thoughts and therefore makes the problem worse.
Evaluate the cognitive explanation
Research evidence - Research has shown that, compared with controls, people with OCD do experience more intrusive thoughts, develop more elaborate methods to neutralise these thoughts are more likely to experience temporary relief from anxiety after carrying out neutralising acts.
there is also evidence to show that suppressing thoughts leads to greater preoccupation with those thoughts. Salkovskis & Kirk - asked people with OCD ot keep a daily diary in which they recorded the frequency of their thoughts. They were instructed to suppress these thoughts on some days and to allow them in on other days. It was found that the OCD clients recorded almost twice as many intrusive thoughts on the suppression days than other days. This demonstrates how strategies used by those with OCD may be unhelpful - consistent with the cognitive explanation.
Success of therapies - CBT is reasonably effective in treating OCD (e.g. Wilhelm used a Y-BOCS symptom checklist, & found significant improvement in 15 clients after 14 weeks of CBT. This provides support for the cognitive explanation. Eddy - performed a meta analysis of 15 clinical trials carried out between 1980 nd 2001 which in total included 705 patients. Nearly 60% improved with cognitive therapies. However, despite this being consistent with cognitive explanations it does not in itself prove the cognitive explanation (aetiology fallacy).
More description than explanation - Cognitive behaviourists describe fairly accurately what happens in the thought processes of people with OCD but they do not really explain why people develop OCD in the first place. Researchers have come up with particular characteristics associated with OCD (e.g. depression and unrealistically high standards) but this does not explain why they think in such an irrational fashion.
Ignores genetics - Twin and family studies indicate that the development of OCD depends to some extent on genetic factors, but such evidence is ignored by the cognitive theory. Research indicates that a combination of factors is involved in the development of OCD and that it can best be explained using the diathesis-stress model.
Explain cognitive therapies
There are many different forms of cognitive therapies but they focus on changing the irrational thinking that is believed to underlie obsessions and compulsions. Cognitive therapists use various strategies:
a) information - they provide information to educate clients about their misinterpretations of intrusive thoughts (e.g. that touching a doorknob will cause illness) and about the client’s negative expectations.
c) Thought stopping - they teach thought (e.g. about germs/dirt) occurs and then encouraging them to divert their thinking to pre-prepared image or thought. Clients gradually develop the skill of stopping their own thoughts when these threaten to overwhelm them.
Cognitive therapy tackles obsessions and compulsions in similar ways. For obsessions the therapist questions how patients interpret their beliefs, including why they think they are true and why they think the obsessions developed. For example, the person who fears shaking hands may believe the action may pass on germs that may cause them to become ill. Such beliefs can then be challenged and reinterpreted so that shaking hands is no longer experienced as an anxiety-producing activity. A cognitive therapist will also question patients about the value of their compulsive behaviours. For example, a person who compulsively washes his or her hands for 30 minutes at a time may believe that her or she is doing so to guard against infection. When this belief is challenged as false, it can help control the behaviour.
Thought records are also used to help clients consider their dysfunctional thoughts. Clients are required to keep a record of their thoughts and what they did to try to challenge them. The therapist can then discuss the record and challenge unrealistic beliefs.
A client is usually offered 15-20 one hour sessions.
Evaluate Cognitive therapies in terms of effectiveness
Cognitive therapy is rarely used on its own. Many patients receive elective treatment (eg drugs and cognitive therapy) which makes it difficult to evaluate the effectiveness of each. A few studies have looked at effectiveness of CT alone. For example, Wilhelm et al - found a significant improvement in 15 patients who used CT alone over 14 weeks, as measured on Y-BOCS. Jones and Menzies - found a 20% improvement in symptoms from group CT sessions.
It seems that pure cognitive interventions are not as effective as ERP (Eddy et al) One of the reasons for this may be thought-rebound. Thought stopping is very difficult to achieve and may increase the number of obsessional thoughts a client has. However, in combination, CT and ERP are more effective than either on its own (Van Oppen et al). Also, the effectiveness of cognitive therapy is more effective in treating obsessions than compulsions. Cottraux et al - reported that the findings varied depending on whether the effectiveness was assessed at the end of the treatment or at a 1 year follow up. Cognitive therapy and ERP produced comparable levels of improvement at the end of treatment but one year later, only those treated with ERP showed further improvement. One of the advantaged of Cognitive therapy over ERP is the comparatively low dropout rate. This is due to cognitive therapies creating less anxiety than ERP. Adding element of cognitive therapy to ERP can help to reduce dropout and benefit treatment (Abramowitz)
evaluate the appropriateness of cognitive therapies
Nearly all those with OCD has dysfunctional beliefs and obsessions. Consequently it is entirely appropriate that cognitive therapists challenge these beliefs and obsessions in order to make them more accurate. More generally, cognitive factors are very important in OCD - individuals with OCD spend excessive amounts of time thinking about issues in great detail. This justifies a therapeutic approach focussing mainly on changing cognitive processes and beliefs. Also, cognitive therapy is acceptable to the vast majority of OCD patients - as reflected by the very low drop out rates. In comparison to therapies from other approaches, CT takes a relatively short time and does not have any side effects. However, there are issues with the appropriateness of CT. For example, CT requires client effort and is not suitable for all OCD sufferers. Ellis - believed that sometimes people who claimed to be following the principles of CT were not putting their revised beliefs into action and therefore the therapy was not effective. Ellis also claims that some people do not want the direct advice that CT practitioners tend to dispense. They prefer to share their worries with a therapist without getting involved with the cognitive effort that is associated with recovery. It could also be argued that there is an issue surrounding the appropriateness of cognitive therapy as its main focus is on only one part of the disorder i.e. obsessions. However, cognitive therapists would argue that the obsessions lead to the compulsions and therefore if obsessions are tackled, then compulsive behaviours will be reduced. Furthermore, cognitive therapists focus on changing the dysfunctional beliefs without considering why a client has developed these beliefs. there is a case for arguing that it would be more appropriate to base therapy on a clearer understanding of the origins of these beliefs.
Explain the psychodynamic explanation for OCD
Freud explained OCD in terms of unconscious forces and childhood experiences. He believed that OCD mainly stems from a fixation at the anal stage of development at around the age of two years. According to his theory, children derive pleasure at this development stage from their bowel movements, both as a physical release and as a creative act. During toilet training, the child has to accept the will of parents and be neat and clean when its natural preference is to be messy and aggressive. The child feels rage at this restraint but parental pressure also makes the child feel guilty, ashamed and dirty. This gives rise to an intense conflict between the id (wanting to let go) and the ego (wanting to control). This conflict, according to Freud occurs in all children. However, if this conflict is particularly strong and parental restrictions are too strict, development is arrested and so the issues related to this stage become issues in adulthood as well and may produce the symptoms of OCD. As this takes place at an unconscious level, the adult really believes that they are concerned with keeping themselves clean. For example, an adult fixated at the anal stage may use reaction formation (a defence mechanism) to resist the urge to soil and become compulsively neat and tidy. He also believed that OCD could occur when the ego became disturbed by unacceptable obsessions and compulsions. As a result ego defence mechanisms would be used to deal with them e.g. hand washing to cleanse oneself of undesirable sexual impulses.
evaluate the psychodynamic explanation for OCD
Although many children experience conflicts with their parents during toilet training, it is difficult to provide empirical evidence for the idea that these conflicts escalate into OCD several years later. In fact, Milby and Weber - have found no greater incidence of parent-child toilet-training conflicts in people with OCD compared to controls. A further problem for this theory is that it seems less relevant to some obsessions and compulsions than others. For example, it is not clear how obsessions with the orderliness of inanimate objects or engaging in compulsive checking are relevant to toilet training or sexual constraints. Evidence for Freud’s theory comes from case studies during psychoanalysis. It is hard to test the idea of unconscious motivation as it is not directly observable. also, even if it were the case that certain experiences during toilet training were associated with OCD, that wouldn’t establish causality. For example, it could be that OCD and problems with toilet training both reflect a certain type of personality that some children inherit. Several factors (e.g. genetic ones, life events) that seem to be important in the development of OCD are ignored within the psychodynamic approach.
Conclude the psychodynamic explanation
IT is clear that no single explanation can account for a complex disorder such as OCD. It seems likely that OCD develops as a consequence of interaction between psychological, social and physiological factors. This approach is called the diathesis-stress model and sees the individual as having an underlying biological vulnerability to OCD which will develop in response to environmental triggers. these environmental triggers may be stressful life event such as bereavement or divorce.
