Understanding Obsessive Compulsive Disorder (OCD) – A CBT Perspective For Therapists

Obsessive compulsive disorder (OCD) is often identified by the presence of obsessions and compulsions, but effective assessment and formulation require a more detailed understanding of how these experiences relate to one another. Clinicians need to consider not only what symptoms are present, but how intrusive experiences are interpreted, which strategies are used to manage them, and how those strategies may inadvertently maintain distress.

Obsessive-compulsive disorder is characterized by persistent obsessions, compulsions, or, most commonly, both. Obsessions are repetitive and persistent thoughts, images, impulses, or urges that are experienced as intrusive and unwanted and are commonly associated with anxiety or distress. Compulsions are repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession, according to rigid rules, or to achieve a sense of “completeness.”

This article outlines the defining features of OCD and summarizes the cognitive and behavioral processes that can keep it going.

What are the defining features of OCD?

Obsessions may involve repetitive thoughts, such as fears of contamination; images, such as violent scenes; or impulses and urges, such as an urge to harm someone. They are experienced as intrusive and unwanted, and the individual typically attempts to ignore or suppress them, or to neutralize them by performing compulsions.

Compulsions include repetitive overt behaviors and mental acts. Overt examples include washing, checking, seeking reassurance from others and ordering objects. Mental compulsions may include repeating particular phrases to prevent a negative outcome, reviewing a memory to make sure that no harm was caused, or mentally counting objects.

Compulsions might be clearly excessive, such as showering for hours to prevent illness, or they may be unrelated to the feared event in a realistic way, such as arranging objects symmetrically to prevent harm to a loved one.

For OCD to be diagnosed, obsessions or compulsions must be time-consuming - for example, taking more than one hour per day - or cause significant distress or impairment in important areas of functioning. When functioning is maintained, it may require significant additional effort. Symptoms must not be better explained by another medical condition or by the effects of a substance or medication.

How can OCD present?

The content of obsessions and compulsions varies between individuals. Common symptom dimensions include:

• Cleaning, involving contamination obsessions and cleaning compulsions.

• Symmetry, usually involving repeating, ordering, or counting.

• Forbidden or taboo thoughts, including aggressive, sexual, or religious obsessions and related compulsions.

• Responsibility for harm, involving fears of causing or failing to prevent harm and checking, reassurance-seeking, or mental compulsions.

• Difficulties discarding objects when accumulation occurs as a consequence of typical obsessions, such as fears of harming others.

Individuals commonly experience symptoms across more than one dimension.

People with OCD may experience marked anxiety, panic attacks, strong disgust, or a distressing sense of incompleteness or uneasiness until something looks, feels, or sounds “just right.” Although compulsions are not performed for pleasure, they may produce temporary relief from anxiety or distress or a temporary sense of completeness.

Severity varies considerably. Some individuals spend several hours each day experiencing obsessions or engaging in compulsions, while others experience near-constant intrusive thoughts or compulsions that can be incapacitating.

What keeps OCD going?

Research studies have shown that cognitive behavioral therapy is one of the most effective treatments for OCD (Ponniah, Magiati, & Hollon, 2013). By identifying the processes that maintain the problem, CBT therapists are able to support clients to interrupt the maintaining cycle.

In 1985, Paul Salkovskis described key components thought to explain why some people continue to experience OCD. This model has subsequently been refined. Important maintaining factors include interpreting obsessions as dangerous, having a strong sense of responsibility for preventing harm, avoidance, and compulsions or neutralizing behaviors.

Interpreting obsessions as dangerous

Everybody experiences intrusive thoughts and images that seem to “pop” into the mind. People with OCD tend to interpret these experiences as signs of danger.

They may conclude:

• “This means I am bad.”

• “This means I am responsible.”

• “Having this thought means it will happen.”

When an intrusion is judged to be significant, the person is more likely to take action to protect themselves or others. Other difficulties associated with OCD can flow from this appraisal.

Common beliefs in OCD include an inflated sense of responsibility, overestimation of threat, perfectionism, intolerance of uncertainty, and overvaluing the power of thoughts—for example, believing that having a forbidden thought is as bad as acting on it.

A strong sense of responsibility

People with OCD often believe that they could be responsible for causing a terrible and preventable outcome by doing something wrong or failing to act. They may consequently believe that they must take particular care over their thoughts or actions.

An excessively strong sense of responsibility can lead situations to appear more likely, important, or awful than they are.

Avoidance

When someone is worried about a potential threat, attempting to avoid it is understandable. A person who fears contamination may avoid going out. Someone who fears being a danger to their children may avoid being alone with them.

Avoidance reinforces the belief that intrusive experiences are dangerous and must be prevented or regulated. It can also prevent the person from learning how likely it is that the feared outcome will actually occur.

Compulsions and neutralization

Compulsions and neutralizing behaviors are performed in response to obsessions, particularly when feared situations cannot be avoided. Examples include washing one’s hands to avoid contaminating loved ones, saying a prayer to cancel a blasphemous thought, or repeatedly checking electrical sockets before leaving the house.

These behaviors may make the person feel better in the short term. However, they reinforce the belief that the obsession is dangerous and must be managed or controlled.

Clinical implications for assessment and formulation

1. Assess both overt and covert compulsions.

As well as overt examples, compulsions may include subtle, covert behaviors such as reviewing memories, counting, repeating phrases, or other mental acts.

2. Explore the meaning attached to intrusions.

The appraisal of an intrusive thought, image, or urge is more clinically significant than its content. If clients believe intrusions are dangerous, threatening or herald impending doom, the ‘pull’ to neutralise, suppress or avoid can be very strong.

3. Clarify the feared outcome.

Assessment can identify what the individual believes might happen and why that outcome feels especially important.

4. Examine responsibility beliefs.

Explore whether the individual believes they must prevent harm by controlling thoughts, taking extra precautions, or avoiding mistakes.

5. Identify avoidance carefully.

Avoidance of people, places, objects, or responsibilities may form an important part of the maintenance cycle, even if this is not immediately apparent.

6. Formulate the relationship between obsessions and compulsions.

When both are present, there is usually a discernible relationship in content or timing. However, compulsions may occasionally precede recognizable obsessions, particularly early in the disorder. Understanding this relationship can assist treatment planning.

Frequently asked questions

1. Does OCD always involve both obsessions and compulsions?

OCD is characterized by persistent obsessions, compulsions, or, most commonly, both.

2. Are compulsions always visible?

No. Compulsions can include repetitive mental acts, such as counting, repeating phrases, or reviewing memories.

3. Do compulsions make people feel better?

They may provide temporary relief from anxiety or distress or create a temporary sense of completeness. However, this short-term relief can reinforce the belief that the obsession was dangerous and required control.

4. Why does avoidance maintain OCD?

Avoidance reinforces the belief that intrusive experiences are dangerous and can prevent learning about whether feared outcomes are likely to occur.

References

• Ponniah, K., Magiati, I., & Hollon, S. D. (2013). An update on the efficacy of psychological treatments for obsessive–compulsive disorder in adults. Journal of Obsessive-Compulsive and Related Disorders, 2(2), 207–218.

• Salkovskis, P. M. (1985). Cognitive-behavioural problems: A cognitive-behavioural analysis. Behaviour Research and Therapy, 23, 571–583.

• World Health Organization. (2020). International Classification of Diseases, Eleventh Revision (ICD-11): Obsessive Compulsive Disorder.