Chapter 3: Obsessive-Compulsive Disorder (OCD)

Jonathan S. Abramowitz

Laura E. Fabricant

Ryan J. Jacoby

Diagnosis Overview

Obsessive-compulsive disorder (OCD)Obsessions or compulsions Significant distress Noticeable interference with aspects of role functioning

Obsessions Intrusive thoughts, ideas, images, impulses, or doubts that the

person experiences as senseless and that evoke anxiety

Compulsions Urges to perform overt (e.g., checking, washing) or mental (e.g.,

praying) rituals in response to obsessions or to reduce anxiety or distress

DSM-5 Diagnostic Criteria

A. Presence of obsessions, compulsions, or both:

Obsessions:

1. Recurren, persistent, intrusive, unwanted, causing anxiety or distress.

2. Attempts to ignore or suppress such thoughts, or to neutralize them with some other thought or action

Compulsions:

1. Repetitive behaviors or mental acts driven to perform in response to an obsession, or using rules that must be applied rigidly.

2. The behaviors or mental acts are aimed at preventing anxiety, distress, or some dreaded event

B. The obsessions or compulsions are time-consuming (for example, take more than 1 hour a day) or cause clinically significant distress or impairment

Indicate whether OCD beliefs are currently characterized by good or fair, poor, or absent insight

Diagnosis-Related Conditions

Body Dysmorphic Disorder (BDD)• Both OCD and BDD can involve:

• Intrusive, distressing thoughts concerning one’s appearance• Repeated checking

• The focus of BDD symptoms is limited to one’s appearance• Similar psychological treatments are effective for both conditions.

Hoarding• Once considered to be a symptom of OCD, hoarding is now

understood as a separate problem. • Hoarding symptoms are no more prevalent in OCD patients than

those with other psychological disorders

Diagnosis-Related Conditions

Obsessive-Compulsive Personality Disorder (OCPD)Personality traits such as excessive perfectionism,

inflexibility, and need for control that negatively impact interpersonal relationships and functioning

OCPD is ego-syntonic while the obsessive thoughts experienced by individuals with OCD are ego-dystonic 

Other personality disorders, such as avoidant and dependent personality disorder, co-occur with OCD just as frequently

Obsessive-Compulsive and Related Disorders (OCRDs)

• OCD moved from anxiety disorders to  OCRDs, which includes trichotillomania (hair-pulling disorder), excoriation (skin-picking), body dysmorphic disorder (muscle dysmorphia specifier added), hoarding, obsessional jealousy & body-focused repetitive disorder

• Many disorders in new category differ substantially from OCD• OCD compulsions are intentional, in contrast to mechanical or

robotic repetitive behaviors such as tics • Repetitive behaviors in addictive disorders or in trichotillomania

or, are carried out because they produce pleasure, distraction, or gratification while in OCD, the repetitive behaviors primarily reduce anxiety

DSM-5 Diagnostic Criteria for OCD

A. Presence of obsessions, compulsions, or both:

Obsessions:

1. Recurrent, persistent, intrusive, unwanted, causing anxiety or distress.

2. Attempts to ignore or suppress such thoughts, or to neutralize them with some other thought or action

Compulsions:

1. Repetitive behaviors or mental acts driven to perform in response to an obsession, or using rules that must be applied rigidly.

2. The behaviors or mental acts are aimed at preventing anxiety, distress or some

dreaded event

B. The obsessions or compulsions are time-consuming (for example, take more than 1 hour a day) or cause clinically significant distress or impairment

Specifier Indicates whether OCD beliefs are currently characterized by:

good/ fair, poor, or absent insight/delusional (specifier can be used for other disorders)

Tic specifier (current or history of)

Symptoms: Obsessions

Examples of Obsessions

Category Example

Contamination What if I get rabies from driving over a dead animal on the street?

Responsibility for harm or mistakes

What if I hit someone with my car without realizing it?

Symmetry/order The books must be evenly placed on the shelf or else I will have bad luck

Unacceptable thoughts with

immoral, sexual, or violent content

Image of my grandparents having sex

Thought about stabbing my husband in his sleep.

Symptoms: Compulsions

Compulsive rituals are often the most conspicuous and functionally impairing symptoms

Compulsive rituals are often performed to reduce obsessional anxiety about feared consequences

Many individuals with OCD also engage in repeated attempts to gain ultimate certainty that obsessional doubts are invalid

Symptoms: Obsessions

Examples of Compulsive Rituals

Category ExampleDecontamination Wiping down all objects brought into the house for fear of

germs from recently applied pesticides on an adjacent lawn

Checking Returning home after seeing a fire engine to make sure the house wasn’t on fire

Repeating routine activities

Going through a doorway over and over to prevent bad luckRetracing one’s steps to make sure that no mistakes were made

Ordering/arranging

Saying the word “left” whenever one hears the word “right”

Mental rituals Canceling a bad thought by thinking of a good thought

Symptoms: Avoidance and Insight

Avoidance behavior is present in most people with OCD Prevents obsessional fears and compulsive urges

altogether 

About 4% of patients are convinced that their beliefs are realistic (i.e., poor or absent insight)

Prognosis

OCD is a chronic condition with a low rate of spontaneous remission

Left untreated Symptoms and functional impairment fluctuate, with

worsening during periods of increased life stress

With treatmentIncreased rates of symptom remission. Full recovery,

however, is the exception rather than the rule

Demographics

Lifetime prevalence of OCD estimated at between 0.7% and 2.9%

Slight preponderance of females

Typically begins by age 25, although childhood or adolescent onset is not rare

Mean onset age is earlier in males (about 21 years) than in females (22 to 24 years)

Etiology: Learning Model

Mowrer’s two-stage theory of fear acquisition and maintenance

• First stage: Classical conditioning• Neutral stimulus, aka. the conditioned stimulus (CS), paired

with aversive stimulus, aka. the unconditioned stimulus (UCS)• The CS comes to elicit a conditioned fear response, or CR

• Second stage: Operant conditioning• Avoidance behaviors reduce anxiety; avoidance is negatively

reinforced by the immediate reduction in distress. • Compulsive rituals develop as an escape behavior from

obsessional fear when avoidance is impossible

Etiology: Cognitive Deficit Models

• Proposes that OCD symptoms arise from abnormally functioning cognitive processes, such as memory

• Cognitive deficit models cannot account for:• Heterogeneity of OCD symptoms• The fact that similar mild cognitive deficits are

found in many psychological disorders

• If cognitive deficits play a causal role in OCD, it is most likely to be a nonspecific vulnerability factor

Etiology: Cognitive Behavioral Models

• Based on Beck’s cognitive theory• Emotional disturbance is brought about by how one

makes sense of situations or stimuli

• Unwanted intrusive thoughts (i.e., thoughts, images, and impulses that intrude into consciousness) are a normal experience

• Intrusions develop into a clinical obsession if the person believes they have serious consequences

• Compulsive rituals and avoidance represent efforts to remove intrusions and prevent feared consequences

Etiology: Salkovski’s Model

• Salkovski’s two reasons that compulsions/avoidance become persistent and excessive:1. Negatively reinforced by their ability to reduce distress2. They prevent people from learning their appraisals of

intrusions are exaggerated and unrealistic

• Psychometric research indicates that there are three principal domains of dysfunctional beliefs associated with OCD symptoms• These types of beliefs confer vulnerability to the onset or

worsening of obsessive-compulsive symptoms

Etiology

Domains of Dysfunctional Beliefs in OCD

Belief Description

Inflated responsibility/ overestimation of threat

Belief that one has the power to cause or prevent negative outcomes. Belief that negative events are likely and would be unmanageable 

Exaggeration of the importance of thoughts

and need to control thoughts

Belief that the mere presence of a thought indicates that the thought is significant. Belief that complete control over one’s thoughts is both necessary and possible 

Perfectionism/intolerance of uncertainty

Belief that mistakes and imperfection are intolerable. Belief that it is necessary and possible to be 100% certain that negative outcomes will not occur

 

Etiology: Pyschosocial Factors

Dysfunctional relationship patterns can promote the maintenance of OCD symptoms

Accommodation Friend or relative participates in rituals, facilitates avoidance

strategies, assumes daily responsibilities, or helps to resolve problems resulting from obsessional fears and compulsive urges

Prevents the natural extinction of obsessional fear and ritualistic urges

Criticism, hostility, and emotional overinvolvement are associated with premature treatment discontinuation and symptom relapse

Etiology: Serotonin Hypothesis

Obsessions and compulsions arise from a hypersensitivity of the postsynaptic serotonergic receptors

Three potential lines of evidence:

1. Medication outcome studies supportive

2. Studies of biological markers—such as blood and cerebrospinal fluid levels of serotonin metabolites—are inconclusive

3. Results from the pharmacological challenge paradigm largely incompatible

Etiology: Structural Models

Structural models hypothesize that OCD is caused by neuroanatomical and functional abnormalities in particular areas of the brainOrbitofrontal-subcortical circuits connect brain regions

involved in information processing with those involved in the initiation of behavioral responses

Two pathways: direct and indirectOveractivity of the direct pathway is thought to give rise

to OCD symptoms

Etiology: Biological Models

No explanation has been offered for how neurotransmitter or neuroanatomical abnormalities translate into OCD symptoms For example, Why does hypersensitivity of postsynaptic

receptors cause obsessional thoughts or compulsive rituals?

In addition, biological models are unable to explain: OCD symptoms are generally constrained to particular

themes Why someone would experience one type of obsession

(e.g., contamination), but not another (e.g., sexual)

Treatment: CBT

Successful treatment for OCD symptoms must accomplish two things:

1. Correction of maladaptive beliefs and appraisals

2. Termination of avoidance and compulsive rituals preventing self-correction of maladaptive beliefs and extinction of anxiety

Functional assessment Detailed information about antecedents and consequences of target

behaviors and emotionsIncludes:

• Assessment of obsessional stimuli• Assessment of avoidance and compulsive rituals• Self-monitoring

Treatment: Exposure and Response Prevention (ERP)

Confrontation with stimuli that provoke obsessional fear but that objectively pose a low risk of harmSituational or in vivo exposureImaginal exposure

Habituation Over time, the anxiety (and associated physiological

responding) naturally subsides

Treatment: Exposure and Response Prevention (ERP)

FormatFew hours of assessment and treatment planning15 (daily or twice-weekly) treatment sessions, 90 minutes eachIf intensive regimens are impractical, conducting the treatment

sessions on a weekly basis works well for individuals with less severe OCD

Self-supervised exposure homework practice assigned for completion between sessions

Home-based self-supervised exposure exercises must last long enough for the anxiety to dissipate

Treatment: Exposure and Response Prevention (ERP)

Therapist must provide cogent rationale for how ERP will be helpful in reducing OCD

Exposure exercisesBegin with moderately distressing situations, stimuli, and images,

and progress to the most distressing situationsBetween each treatment session, patient continues exposure

exercises for several hours in different environmental contexts without the therapist

Exposure to the most anxiety-evoking stimuli is completed during the middle third of the treatment program

During later sessions, therapist emphases generalization and of continued application of ERP procedures after treatment

Treatment: Exposure and Response Prevention (ERP)

Foa and Kozak hypothesized that ERP produces its effects by correcting patients’ overestimates of danger that underlie obsessional anxiety

Three requirements for successful outcome with ERP1. Physiological arousal and subjective fear are evoked during exposure.

2. Within-session habituation

3. Between-sessions habituation

Inhibitory learningEnhance the recall of the new associations relative to the older, threat-based

associations

Combining exposure and response prevention is more effective than using either of its individual components

Treatment: Exposure and Response Prevention (ERP)

Majority of OCD patients experience substantial short- and long-term benefits~83% of patients are responders (at least 30% symptom reduction)

at posttreatment76% were responders at follow-up

Superior to wait list, progressive muscle relaxation, anxiety management training, pill placebo, and pharmacotherapy with serotonergic medication 

Effectiveness studies conducted in real world show that more than 80% of patients who complete treatment achieve clinically significant improvement

Treatment: Cognitive Therapy (CT)

Rational and evidence-based challenging and correction of faulty and dysfunctional thoughts and beliefs that underlie emotional distress

16-session CT include: Learning to conceptualize obsessive intrusions as normal stimuli Identifying and challenging anxiety-provoking thoughts associated

with obsessions with Socratic questioningChanging dysfunctional assumptions to nondistressing beliefsBehavioral experiments to test out the new beliefs

Studies suggest relatively equivalent efficacy of CT and ERPCT reduces drop out from ERP

Treatment: Pharmacological

On average, serotonin medications produce a 20% to 40% reduction in obsessions and compulsions

Advantages ConvenienceLittle effort on the patient’s part

LimitationsRelatively modest improvement and residual symptoms High rate of nonresponse (40% to 60%)Side effects (may be minimized by adjusting the dose)Once terminated, OCD symptoms typically return rapidly