Center for Cognitive Therapy
Mark E. Oakley, Ph. D.
The essential characteristics of Obsessive-Compulsive Disorder are recurrent obsessions or compulsions that are severe enough to cause significant impairment with a person's normal routine or occur for more than I hour per day. Obsessions are recurrent and persistent thoughts, impulses or images that are experienced as intrusive, inappropriate, and cause marked anxiety or distress. Compulsions are repetitive behaviors or mental acts that are intended to prevent or reduce distress from a dreaded event or situation.
Common obsessions include:
- Fears of contamination.
- Fears of hurting or killing someone.
- Fears of forgetting to do something.
- Fears of doing something embarrassing or immoral.
Common compulsions or rituals include:
- Excessive washing or cleaning.
- Repeating actions.
- Hoarding or saving items.
- Putting things in a set pattern.
OCD is a relatively common problem. It has been estimated by recent community studies that there is a lifetime prevalence rate of 2.5% of the general population that meet the diagnostic criteria for this disorder. The majority of individuals who do not seek treatment experience a waxing and waning chronic course that may be exacerbated by stress. Recent research has demonstrated that 90% of the general population have thoughts similar to those experienced by individuals with OCD. The major difference is that those people with OCD are more distressed by these thoughts. Because of this distress, individuals with OCD develop elaborate strategies to avoid these thoughts. These strategies are generally ineffective and therefore individuals often turn to other methods to reduce anxiety such as performing some action. While this may temporarily relieve anxiety, in most cases rituals are performed because of the belief and prediction that if the person does not engage in the ritual some dire consequence will occur or they will not be able to tolerate the anxiety they anticipate experiencing.
Exposure and Response Prevention (ERP) with Cognitive Therapy are effective treatment strategies with OCD. An average of approximately 83% of patients who undergo treatment show a moderate to marked improvement (generally defined as a 30% reduction in symptoms). The average length of treatment is 15 to 20 sessions with some of the early sessions being extended exposure sessions of 90 minutes duration or longer, two to three times per week for the first two weeks. Treatment consists of identifying situations that would elicit OCD symptoms and establishing a hierarchy of anxiety producing situations from least anxiety provoking to the most. The individual then directly confronts the situation and the exposure is continued without engaging in any rituals or mental control strategies until the anxiety is reduced by at least half.
OCD patients typically engage in extensive avoidance, neutralization, and other mental control strategies. Although these strategies are intended to decrease anxiety, self monitoring and analyses usually indicate that these strategies are not only ineffective but aggravate and maintain anxiety and OCD symptoms.
ERP is utilized with Cognitive Therapy in the format of a series of behavioral tests consisting of purposely confronting feared stimuli that are predicted would lead to anxiety that could not be tolerated. This general strategy essentially involves performing the following steps with all identified situations in the hierarchy of feared items/situations:
- Do nothing
- See what happens
The outcome of these behavioral tests invariably leads individuals with OCD to conclude that purposeful exposure to feared circumstances without engaging in control strategies either do not lead to increased anxiety or anxiety is very time limited and is tolerable. Most importantly, the fear that NOT engaging in a control strategy such as neutralization, avoidance or other mental control strategies will lead to a never ending spiral of anxiety and OCD symptoms is discovered to be untrue.