The Nature and Treatment of Obsessions and Compulsions: Abramowitz (2017) Flashcards
obsessions =
Intrusive, persistent thoughts, images, doubts, and ideas that people experience as unwanted.
Further, their content is incongruent with the person’s belief system, and they are resisted in that they are accompanied by the sense that they must be dealt with, neutralized, or avoided (by compulsions).
compulsions=
(urges to engage in) behaviors that serve to reduce or remove obsessional distress. Thus, they have a specific function (in contrast to many impulsive behaviors which are carried out because they produce pleasure, distraction, or gratification).
symptom dimensions of OCD =
- contamination
- responsibility for harm & mistakes
- incompleteness (order/symmetry/exactness/arranging rituals)
- taboo thoughts (violent/sexual/blasphemous)
blasphemous=
insulting a God
what is another strategy to deal with obsessions, aside from compulsions
Avoidance: this is usually done to prevent unwanted thoughts, negative outcomes, uncertainty, and compulsive urges.
cognitive-behavioural model of OCD
the idea that obsessions develop when a person mistakenly appraises intrusions (which are generally normal experiences) as threatening, personally significant, or provoking uncertainty that the person perceives as unmanageable. These appraisals evoke distress and motivate the person to engage in compulsions.
compulsions are viewed as counterproductive:
- Preventing learning by providing an immediate escape from anxiety and doubt, preventing the person from learning that upsetting thoughts, anxiety, and uncertainty are manageable and that obsessional distress eventually subsides naturally over time.
- Increasing obsessions by serving as reminders of obsessional intrusions, triggering their recurrence.
- Preserving misinterpretations: they maintain dysfunctional beliefs and misinterpretations of obsessional thoughts, because when feared consequences do not occur, this will be attributed to the performance of the compulsion.
core dysfunctional belief domains that are thought to underlie obsessions
- inflated responsibiltiy
- thought-action fusion
- need to control thoughts
- overestimation of threat
- perfectionism
- uncertainty intolerance
thought action fusion
The mere presence of a thought indicates that it is significant or that it increases the probability of the corresponding behavior or event
overestimation of threat=
Negative events are especially likely and would be especially awful
uncertainty intolerance=
It is necessary and possible to be completely certain that negative outcomes will not occur
treatment targets van CBT bij OCD
a) correct maladaptive beliefs and appraisals
b) decrease avoidance and compulsive behaviours that serve as barriers to the correction of the maladaptive beliefs
conditioning approach=
the idea that obsessions and compulsions (and other pathological fears) are acquired by classical conditioning and maintained by operant conditioning.
Research provides support for some aspects of this approach, but traumatic conditioning experiences do not appear to be necessary for the development of obsessions.
Obsessions arise from experiences during which they become associated with negative experiences (classical conditioning). Subsequently, obsessions are maintained by anxiety-reduction behaviors (negative reinforcement) that prevent its natural extinction (operant conditioning).
voorbeeld conditioning approach
Obsessional fears that the number 13 will cause bad luck can arise from experiences during which anxiety becomes associated with this number (classical conditioning). Subsequently avoiding the number 13 and performing compulsive praying rituals to prevent bad luck provides temporarily relieve of anxiety (operant conditioning).
exposure therapy and response prevention=
direct confrontation with feared stimuli to foster extinction learning.
welke soorten exposure worden bij OCD het meeste toegepast
in vivo & imaginal
2 models of the mechanism of exposure
- emotional processing theory (EPT)
- inhibitory learning theory
emotional processing theory=
the confrontation with a feared stimulus activates a fear structure and integrates information that is incompatible with it (habituation of fear), resulting in the development of a new non-fear structure that replaces the original one.
-> But research suggests that neither fear activation nor habituation consistently predicts outcomes.
fear structure=
a set of propositions about the feared stimulus, response, and their meaning that is stored in memory
inhibitory learning theory=
fear associations are not removed during extinction but remain intact.
This leads to 2 subsequent meanings of the feared stimulus: a fear-based excitatory meaning and a safety-based inhibitory meaning. The former can be recovered over time or in other contexts.
-> Exposure helps patients develop new non-threat associations and ways of enhancing the accessibility of them (over the threat associations) in different contexts and time.
response prevention=
a necessary add-on to exposure therapy that involves resisting urges to perform compulsive behaviors that serve as an escape from obsessive fear. This allows for prolonged exposure and facilitates the extinction process.
waar heeft exposure therapy en response prevention toegeleid
Research has found that exposure therapy is superior to response prevention in reducing obsessions, while response prevention is superior in decreasing compulsions. As expected, a combination of the 2 techniques (ERP) results in more improvement overall.
cognitive restructuring=
a technique that involves rational and evidence-based challenging and correction of dysfunctional thoughts and beliefs to modify behavioral responses to obsessional stimuli so that they no longer provoke strong urges to perform compulsive behavior. Sometimes in combination with behavioural experiments, to facilitate the acquisition of corrective information.
acceptance and commitment therapy in OCD
a set of techniques to foster acceptance of anxiety, uncertainty, and obsessional thoughts. psychological flexibility (acceptance of negative emotional states) is associated with a reduction in long-term distress.
While challenging and changing cognitions is not an explicit goal of ACT, changing how the
individual relates to their obsessions implicitly involves a change in beliefs.
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Fostering acceptance can complement enhancing inhibitory learning in exposure experiments: if the obsessional fear can be tolerated to a larger degree, inhibitory associations can be maximally acquired.
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wat zijn dus de onderliggende mechanismen van ERP, CBT en ACT:
the promotion of new inhibitory learning via shifts in interpretations of obsessional thoughts and related feelings.
treatment obstacles
- fears of long-term or unknowable consequences
- disgust & ‘just not right’ experiences
- family accommodation
fears of long-term or unknowable consequences =
Some obsessions are about feared consequences that take place in the very long term (‘I will get cancer in 40 years’) or that are unknowable (‘I am going to hell’). In this case, exposure or cognitive therapy could focus more on disproving beliefs about not being able to tolerate living with uncertainty. In addition, expectancy tracking can be used to consolidate the learning experiences.
Expectancy tracking =
the continuous asking for summaries about what the patient has learned during exposure.
disgust and ‘not-just-right’ experiences
In case of obsessions that are related to feelings of disgust or in case of ‘not-just-right’ experiences (when things feel ‘incomplete’), expectancy tracking can also be sued to help individuals learn that these experiences can be tolerated.
family accommodation=
A patient’s close relatives, partners, or friends can sometimes accommodate the patient’s obsessive-compulsive behaviors by helping them with rituals, avoidance, and resolving problems resulting from them. It is related to more severe symptoms and poorer treatment outcome. When accommodation is the case, treatment should also focus on teaching the patient and their relative to identify and understand the role of accommodation, and train them to stop it.
