Week 5: OCD

Question 1

What disorders are categorized under: “Obsessive compulsive and Related Disorders” (4)

Answer 1

o OCD
o Body Dysmorphic Disorder (BDD)
o Hoarding Disorder
o Trichotillomania & Skin-picking Disorder

Question 2

HOW DO COMPULSIONS MAINTAIN OBSESSIONS? (Model, 4 Stages)

Answer 2

1. Obsession
2. Anxiety
3. Compulsion
4. Relief

Repeat

Question 3

What are some key cognitive features of OCD and are they relatively easy to treat? (6)

Answer 3

Often very hard to treat

*Thought-action-fusion (TAF):
- Your thoughts have negative consequences
- Your negative moral thoughts are equal to a negative moral action

*Exaggerated responsibility:
- Exaggerated conviction that the patient is able to prevent or cause a negative event.

*Controllability of thoughts:
- Control wishes and thoughts

*Perfectionism:
- Conviction that there is ONE right way to do things.

*Overestimate danger:
- The risk of serious negative incidents is overestimated

*Intolerance of uncertainty:
- The idea that the patient cannot bear a situation without a 100% certainty

Question 4

What obsessional theme is often concealed during therapy sessions?

Answer 4

Blasphemy

Question 5

Which noteworthy disorders are comorbid with OCD? (4)

Answer 5

*About 30 to 55% comorbid with depression (MDD);
o 65% life-time history of MDD
o Decreased daily functioning and withdrawal

*25% concurrent with another anxiety disorder most often GAD, social phobia and PTSS

*8% concurrent with an eating disorder
o Need to control something

*5% concurrent with Tourette’s syndrome

Question 6

Describe the Learning Theory View of OCD (2-Factor Theory)

Answer 6

Obsessions give rise to anxiety or distress

Compulsions reduce obsessional anxiety

The performance of compulsions prevents the extinction of obsessional anxiety
-Primary maintaining factor

Compulsions are negatively reinforced by the brief reduction of anxiety they engender

Question 7

How do you apply the inhibitory model to OCD treatment? (4)

Answer 7

1. Learning that CS (= touching the ground) does not lead to US (= contamination)
2. “Exposure as a behavioral experiment”:
   -Identify misinterpretation:
   CS → US (If I do not control, then the house will catch on fire. If I do not wash my hands, then I will become contaminated. If I do not pray 7 times, then something terrible will happen.)
   -Score the credibility of the CS → US relation
   -Make an overview which arguments are valid in favor and against the CS → US rule
   -Use exposure as an experiment to investigate if the CS → US relationship can be tested empirically
3. Disconfirmation of the CS → US relationship means that a new association will be learned: CS → non-US relation
4. The old association CS → US needs to be inhibited

Question 8

Effects of repeated (experimental) checking in OCD (n=30) vs. ctrls (n=30):

(Results?)

Answer 8

Repeated checking reduces certainty

Not much difference between OCD and healthy controls

Question 9

Empirically supported psychological treatments to OCD? (2)

Answer 9

Psychological treatment
o Exposure and Response Prevention (ERP)
o Cognitive Therapy

Combined Medications + ERP

Question 10

Steps to conducting exposure for OCD: (5)

Answer 10

Before exposure:
1. Make concrete what the aim of the exposure is – make concrete what the “If I do…., then … will happen” expectancy is.
2. Register the credibility of the “If (cs)…, then (US)” expectancy instead of the level of anxiety

During exposure:
3. Try to provide the patient with as much disconfirmative information in different contexts!

After exposure:
4. Check if the the “If (cs)…, then (US)” expectancy has become true or disconfirmed
5. How do you know this? Have information provided why the CS is not an adequate predictor of the US (beware of safety behavior!).

Question 11

True or False:
Most people with OCD had worsened symptoms during pandemic

Answer 11

Most groups of OCD clients DID NOT GET WORSE
o Contamination sub-group worsened.

Question 12

Why do people hoard?

Answer 12

Fear of throwing things away?

Question 13

Best way to treat hoarding?

Answer 13

Prescribe:
-CBT and/or anti-depressants
–Quite resistant, and becomes more severe over time

Question 14

Prognostic Factors in Body Dysmorphia?

Answer 14

Prognostic Factors

Environmental
Often abuse

Genetic and Physiological

Treatment: CBT

Question 15

Among the general population, what kind of thought intrusions are most common?

Answer 15

Doubting

Question 16

How can (almost) everyone experience unwanted intrusions, while only some develop OCD?

Answer 16

“Obsessions are caused by catastrophic misinterpretations of the significance of one’s
thoughts (images, impulses)”

Question 17

Types of most distressing UITs (MD-UIT) (3)

Answer 17

Doubt most distressing

Sexual and religious/immoral least

Significant differences in ‘other’ and victim categories
a. Ankara / Thessaloniki: contamination
b. Chambery: harm/injury/aggression
c. Hong Kong: religious or immoral
d. Makeni / Montreal sexual

Question 18

Characteristics of MD-UITS (Significant and non significant differences) (5)

Answer 18

Significant differences
a. Frequency
b. Difficulty removing

No difference
a. Distress
b. Interference
c. Importance of removing UIT

Question 19

Appraisal which made UIT more noticeable (5)

Answer 19

a. Intolerance of anxiety
b. Importance of the thought
c. Overestimation of the threat
d. Need to control the thought
e. Appraisals of responsibility

Question 20

Control strategies more likely to use for UIT (5)

Answer 20

a. Self-reassurance

b. Thought stopping

c. Reasoning

d. Thought replacement

e. Distraction

Question 21

Salkovkis: Misinterpretation of obsessions has 4 effect

Answer 21

1. increased discomfort, including anxiety and depression
2. focusing of attention both on intrusions themselves and triggers in the environment that may increase their occurrence
3. increased accessibility to and preoccupation with the original thought and other related ideas
4. behavioral responses, including ‘neutralizing’ reactions

Question 22

How does Over-Control increase stress in OCD? (3)

Answer 22

 Direct and deliberate attention to mental activity can modify the contents of consciousness

 Efforts to deliberately control a range of mental activities result in failure and even opposite
effects.

 Attempts to prevent harm and responsibility for harm increases the salience and accessibility of the patients’ concern with harm, neutralizing efforts directed at preventing harm

Question 23

As therapist, what do you want to do with a client’s intrusions? (1 method, 5 steps)

Answer 23

Changing the way intrusions are interpreted by normalizing them

Most therapy techniques focus on reappraisal
-Key component: normalizing the experience
of intrusions
-Guided discovery:
a. Who has obsessional thoughts?
b. How common are intrusive thoughts?
c. Do they occur only in people suffering from OCD?
d. Why are intrusions so common?
e. Are they of any use?

Question 24

Methods for challenging assumptions in OCD?

Answer 24

Downward arrow technique

Specific questionnaires as the Responsibility Attitudes Scale

Therapy should aim to help the patient to understand the way in which an apparently innocuous thought can evoke so much discomfort and challenge the assumptions at each level

Question 25

How effective are CBT strategies for treating OCD?

Answer 25

Meta-analyses indicate that ERP is as effective or more effective than treatment with serotoninactive antidepressant medication

Cognitive treatment:
a. without exposure is at least as effective as behavioral therapy
b. as effective as a combination of cognitive treatment with fluvoxamine or behavioral
treatment with fluvoxamine

Integrated CBT is effective for obsessional ruminations

For some patients CBT guidance on the phone is both helpful and highly economical.
a. Comes from ‘stepped-care’ treatment

Question 26

Besides repeated checking, uncertainty is also increased through… (3)

Answer 26

o Prolonged visual fixation
o Text repetition
o “OC-reasoning”

Question 27

Motor perseveration reduces automatic access to ____________________

Answer 27

the meaning of the activity

Question 28

Other Uncertainties and Perseveration Patients are not only uncertain about memory, but also about… (3)

Answer 28

 Understanding written text
 Perception
 Reasoning

Question 29

Semantic satiation

Answer 29

While the meaning of the word remains intact, a subjective alienation takes place.

Occurs when a word is repeated over and over.

Question 30

How does uncertainty affect Visual Perception in OCD? (4)

Answer 30

1. Most patients seem to be worried about the validity of visual perception
2. Then they intensely look at some object to ascertain that they are adequately switched off.
3. Perseverative staring at gas stoves or light bulbs induces uncertainty about visual perception and dissociative experiences
4. These effects take place fast

Question 31

How can uncertainty of reasoning manifest in OCD?

Answer 31

The type of question being tried to answer by OCD patients:
“Can I rule out that such and such might occur?”

NB: The answer to this question is always no and therefore not informative
-Although perseverative reasoning does not increase uncertainty about the outcome
-The credibility of the outcome significantly increases

Question 32

Rachman: Compulsive checking occurs when people (4)

Answer 32

-have a belief of an elevated responsibility to prevent harm

-are unsure that the perceived threat has been reduced or removed

-The intensity and checking is determined by three multipliers:
o Increased responsibility
o Probability of harm
o Anticipated seriousness of harm

-The recurrency is promoted by a self-perpetuating mechanisms, comprising four elements:
o Paradoxical increases in responsibility
o Perceived probability of harm
o Reduced confidence in memory
o Absence of a certain end of the threat

Question 33

Notable features of checking compulsions? (4)

Answer 33

-Checking occurs predominantly in the person’s own home

-Most checking is carried out when the person is alone

-Compulsions intensify when person is depressed

-Most intense when person feels responsible for the act concerned

Question 34

Why would someone with OCD engage in neutralizing activities?

Answer 34

Aimed at canceling the obsessions and compulsions

Attempt to prevent feared event

Neutralizing, compulsive acts and reassurance-seeking share common features and all can be construed as attempts to reduce probability of a nasty event to occur.

Question 35

4 components of self-perpetuating mechanism

Answer 35

Unsuccessful search for certainty that the possible harm has been reduced or removed
o There is no certain end, because the predicted scenarios are bizarre and obscure. Without a natural end, the search for safety checking continues.

Uncertainty of memory of checking
o Confidence in recall of checking declines: The more checking you do, the less confidence you have in your memory of checking
o Direct loss of memorial confidence when responsibility goes high

Cognitive bias
o people feel that the probability of harm occurring is elevated when they are responsible, in charge or in duty.

Another cognitive bias
o Increase in personal responsibility after completion of safety check.

Question 36

Factors which multiply likelihood of checking behaviour (3)

Answer 36

Perceived responsibility

Perceived probability of the feared harmful event occurring
o This is elevated when the person in in a position responsible for ensuring safety

Perceived severity or ´cost´ of the feared harmful event

Question 37

If a person’s responsibility is removed, how much compulsive checking will take place?
Regardless of the remaining to multipliers.

Answer 37

little to none

Question 38

Clinical implications around checking behaviours? (3)

Answer 38

1. Attempt to reduce multipliers; primary emphasis on inflated responsibility
   a. With behavioral experiments
2. Modify patient’s maladaptive interpretations
   a. Energetic cognitive therapy
3. Unravel and dismantle self-perpetuating mechanism
   a. Behavior experiment: response prevention

Question 39

Difference in compulsive checking and compulsive cleaning

Answer 39

Cleaning:
o Aim to remove harm that possibly occurred
o Protect oneself from harm

Checking:
o Aim to prevent future harm
o Protect others from harm