Cognitive Behavioural Therapy for OCD: Clark

    

Cognitive Behavioural Therapy for OCD: Clark

. 10

 Contents
Part 2 Cognitive –Behavioural Theory and Research    1
Chapter 3. Behavioural Perspectives on OCD    1
Behavioural Theory    2
Behaviour Therapy for OCD    3
Behavioural treatment of obsessions    3
Empirical Status of Behaviour Therapy (ERP)    4
Chapter 4. Neuropsychology and Information Processing in OCD    4
Chapter 5. Cognitive Appraisal Theories of OCD    4
Early cognitive appraisal theories of OCD    4
Contemporary cognitive behavioural theories    5
Salkovskis’s inflated responsibility model    5
Empirical Status    7
Ranchman’s misinterpretation of significance theory    8
The obsessissive compulsive cognitions working group    10

Part 2 Cognitive –Behavioural Theory and Research

Chapter 3. Behavioural Perspectives on OCD

The early thoughts on OCD from a behavioural perspective was that overt compulsive behaviours were anxiety reducing behaviours to respond to the anxiety caused by the obsession.  Thus there is negative reinforcement for the compulsion, however because the compulsion  reinforcers the fear of the obsession, through having to defend against its anxiety there effectively is an escalation in the force of the obsession.  Obsessions were understood to be toxic due to their conditioned association with a prior traumatic event.  In this way OCD is treated much like a phobia. 

This is based on Mowrer(1939) two stage theory of fear and avoidance, where first of all there is classical conditioning that links the aversive thought with a neutral object, such that the neutral object elicits anxiety. Secondly there is an avoidance of the now conditioned object.  However avoidance isn’t always possible and so then reassurance seeking happens. This again is negatively reinforced, where there is an aversive thought, which creates anxiety, which leads to reassurance seeking to reduce the anxiety, thus reassurance seeking is negatively reinforced.

In 1966 Meyer produced a behavioural treatment called exposure and response prevention, the two factor theory provided the theoretical underpinning for ERP. In the intervening 30 years clinical trials showed 60-85% of patients who complete ERO show significant symptom improvement. 

Behavioural Theory

Obsessions

Rachman (1971) argues that obsessions, like phobic stimuli are conditioned noxious stimuli cause distress to the client which results in avoidance behaviours, e.g. compulsions.  Obsession are different from phobias though as they are more associated with depressive responses. Obsessions persist because clients fail to habituate to the intrusive thought and indeed they increase their sensitivity and responsiveness to the cognition.  This increase can be caused through:

1.       Personality vulnerabilities (introversion, excessive conscientiousness, moral rigidity)

2.       Periods of stress

3.       Heightened arousal

4.       Perceived loss of control

Behaviourally compulsions are seen as a covert avoidance that is distinct from the overt avoidance of avoiding the stimuli to the obsession.

Rachman and Hodgson (1980) propose there are 5 factors that explain vulnerability to obsession:

1.       Presence of dysmorphic mood

2.       Exposure to stress

3.       Intolerance of thoughts

4.       Heightened sensitivity to threatening stimuli

5.       Personality constellation characterised by dysthemia, high emotionality and introversion

Dysthemia=Persons moods are regularly low

Compulsions

Compulsive rituals are seen to persist because of avoidance learning.  Avoidance learning is where a learned activity prevents exposure to a feared stimuli, and therefore reduces anxiety.  Avoidance activity is strengthened through operant conditioning.  However the reduction of avoidance activity is very short lived, hence it is repeated.  There are some instances where there is no anxiety reduction post compulsion but in these instances there can be seen negative meta- cognitions about the compulsion producing feelings of guilt etc.  Alternatively the compulsion may be to prevent a long term feared consequence at the expense of a short term increase in anxiety.

Empirical Support

Because classical conditioning is the behaviourist’s explanation for the genesis of obsessions, this provides a directly testable hypothesis.  There is considerable 80% empirical support for this (Steketee 1985) however 20-30% occur without external stimuli. Rachman (1980) shows there is little relation between obsessions and environmental events.

When a client has an intrusive thought then their anxiety goes up. In this heightened state then they are less able to deal with this thought, by distraction, acceptance etc. Heightened levels of anxiety also increase their sensitivity to the thought and their catastrophisation of it.  However if you repeat the obsessional thought then the client doesn’t get reciprocally increased levels of anxiety as the behavioural model would indicate.

Another critique of the behavioural account is that there are some clients as much as 20% who do not get any anxiety reduction in their neutralising behaviours., indeed the anxiety reducing affects of compulsions may be seen when clients replace any anxiety image with a more pleasant one (Marks 2000).

Behaviour Therapy for OCD

ERP

Meyer (1966) argued that if the client is faced with their feared stimuli without doing their neutralising behaviour they will learn that their feared consequence does not occur.

Exposure

Exposure just shows that anxiety tails off by itself and will lead to habituation. So the fear response cannot be maintained at such a high level and after a while it reduces and the patient learns that the feared object does not have the feared consequence.  The key to this is the encouragement and support that the therapist gives to the client to face their feared object.  The therapist should avoid reassurance but should say that the anxiety response will go of its own accord.  So exposure teaches that you can manage the anxiety elicited by the feared object without the neutralising behaviours.

Response prevention

In response prevention, the client encounters the feared object without performing anything of their neutralising behaviours, either overt or covert.  

Behavioural treatment of obsessions

20% of OCD clients have obsessive ruminations without overt compulsions. This is not effectively targeted by ERP Rachman (1976). Rather  obsessional ruminations are treated by thought stopping, paradoxical intention, thought satiation or habituation training.

Thought stopping

Its efficacy remains doubtful , technique is to get the client to have their unwanted thoughts, then shout stop, or use a rubber band, until the thoughts start stopping.  Thought stopping is an ad hoc technique and has no underlying rationale apart from the fact that it can work.

Paradoxical Intention

Here the client has the obsessional thought, and to deliberately dwell on it, and elaborate it and exaggerate it in an effort to be convinced of its validity. Very little research has been published on it efficacy, apart from Solyom (1972)

Habituation Training

Clients hold onto their obsessions for 15 minutes without trying to neutralise them.  Effectively thought exposure.  Again not many studies to support this one.

Audiotaped habituation  training

One of the reasons why thought exposure may not work, is the client wont fully expose themselves via covert safety behaviours, distraction, thought stopping, thought replacement etc. and this is where the audio tape comes in.

Empirical Status of Behaviour Therapy (ERP)

ERP has long been recognised as effective as a treatment for OCD, with more severe cases then you use it in conjunction with pharmacotherapy.  13 to 20 sessions was considered the optimum treatment length.  ERP has in studies been shown to be very effective 80% postreatement, although 25% of people refuse ERP and another 3-12% will not complete treatment.  This reduces the  figure to 36%.. Also the type of OCD client used in these studies are cleaning and checking not the range of other OCD distresses. ERP is most suitable for overt compulsions, but is relatively ineffective for covert compulsions.

Who benefits from ERP?

Younger age at symptom and treatment onset leads to better treatment gains. Lower income leads to worse outcomes.  People with moderate to severe depression will find ERP less effective.  People who don’t see their compulsions as excessive will show poor treatment outcome.

Chapter 5. Cognitive Appraisal Theories of OCD

Early cognitive appraisal theories of OCD

Beck didn’t consider CT appropriate for obsession and the first time CT had clinical applicability to it was Salkovskis (1985).

Carr (1974)  proposed that obsessional states are characterised by an abnormally high subjective estimate of the probability that unfavourable outcomes will occur.  Compulsive rituals then develop to reduce this anxiety, so the difference with the behaviourists is that the latter see classical conditioning associating the conditioned stimulus with the conditioned response, whereas the cognitivists see it as thinking errors that do this.

Thus anxiety becomes a product of probability * harm, which in OCD is high as there is a high probability the client thinks that it will happen, and they have low estimation of their ability to cope with it.  Cognitive compulsions will occur when an appropriate threat reducing behaviour is not available.

The initial thinking errors of overestimation of threat and underestimation of ability to cope can be understood as forming out of some prior maladaptive beliefs:

1.       It is necessary to be perfect

2.       Mistakes should be punished

3.       One has the power to prevent terrible outcomes by magical rituals or ruminative thinking

4.       Certain thoughts are unacceptable as they either create or show that you want aversive outcomes

5.       It is easier and more effective to engage in neutralising activities than to confront ones feelings

6.       Feelings of loss of control and uncertainty are intolerable

There is a relation between the faulty primary and secondary appraisals to feelings of loss of control and uncertainty.

Contemporary cognitive behavioural theories

The appraisal theory  is key to current cognitivists. This is firstly an ego dystonic thought\image is had=>misinterpretation of this, that means it will happen, or I will do it=>anxiety=>neutralisation=>short term +feeling of control, -anxiety long term increase levels of fear of the intrusion and increasing of the neutralisation

Salkovskis’s inflated responsibility model

Description of the Model

Unwanted intrusive thoughts

Unwanted thoughts are common to all people and may represent part of a problem solving mechanisms that generate ideas out of our current concerns.  However having had the thought we then need to work out if we need to do something about it, and may well be compelling , if we perceive the thought to be useless then it is ignored.

Inflated responsibility

The difference between a normal intrusive thought and an obsessional one does not lie in its content, frequency or uncontrollability but rather on how we interpret it.  Intrusive cognitions are emotionally neutral to start off with but gain emotional significance depending on a person’s prior experience and the context of the thoughts.  A key assumption is that it is not the obsession per se that causes the problem but the interpretation of it.  Again here is the major difference with the behaviourists who see the conditioning of the obsession as the problem, where the cognitivists see the interpretation of the obsession as the problem.

The inflated responsibility comes through having the belief that through ones actions, ones rituals one can prevent something bad happening.  Having this belief then when an aversive thought happens that signifies personal responsibility then the following sequence happens:

·         The intrusion is associated with increased discomfort and anxiety

·         The intrusion gains greater salience

·         Neutralising responses  are initiated in an effort to escape responsibility

Inflated responsibility can focus either on the occurrence or the content of the thought. The occurrence might suggest I am losing my mind. If the content is that of responsibility I might vomit, get sick and die, then the person becomes responsible to try to stop this.

Salkovskis argues that it is inflated responsibility that distinguishes OCD from other anxiety disorders.

So when a person checks the freezer to ensure that no-one is trapped in there, which on one level she doesn’t believe, she does this to alleviate an elevated sense of responsibility.

Neutralisation

The neutralising behaviour in this model is to neutralised the feeling of responsibility for the action, this in turn leads to a decrease in the levels of discomfort. The neutralising behaviours also prevent the patients from processing any evidence that would disconfirm their inferences of responsibility for preventing highly improbable frightening events.

Overcontrol of mental activity

Another consequence of responsibility appraisals is that individuals with OCD will try too hard to exert control over their intrusive thoughts.  The trouble with thought suppression is it will heighten distress through:

1.       Changing the content of conscious thoughts

2.       It will result in failure and increase the sense of uncontrollability

3.       It will increase the salience of thoughts dealing with harm

4.       It prevents disconfirmation of the belief that harm must be prevented

Obsessional problems are the result of people trying too hard to prevent harm from happening.

Biased cognitive processing

Salkovskis argues that certain logical errors are often seen in OCD and  are the product of pre-existing OCD beliefs.

1.       Responsibility bias

a.       The bias of conflating any personal influence on that outcome, with responsibility for that outcome

2.       Absence of omission bias

a.       Most individuals believe there is less responsibility involved in failing to act as opposed to situations where commissioning an act could bring about negative consequences. Individuals with OCD do not make this distinction.

3.       Misinterpretation of personal agency

a.       Individuals with OCD often mistakenly assume they can foresee possible harmful outcomes as such it triggers sense of responsibility to do something to prevent this negative outcome

4.       Thought action fusion

5.       Errors of decision making

a.       The individual have no idea when to stop their compulsion the criteria for knowing when the ritual is complete may be vague, highly subjective and open to considerable variation

Dysfunctional Assumptions

Salkovskis views vulnerability to OCD in terms of pre-existing assumptions that are triggered by the occurrence of unwanted intrusive thoughts and give rise to the cognitive biases and appraisals of responsibility.  These beliefs are

1.       Responsibility beliefs (not trying to prevent harm to self or others is equivalent to causing the harm)

2.       Thought action fusion (having a thought is like performing the action)

3.       Thought control beliefs(one can and should exercise control of one’s mental activity)

4.       Neutralisation beliefs (one should neutralise in order to prevent possible harm from occurring to others)

Salkovskis proposes 5 pathways that may lead to development of maladaptive responsibility

1.       A generalised sense of responsibility for preventing threat that is encouraged in childhood

2.       Exposure to rigid or extreme codes of conduct

3.       Childhood experiences such as overindulgence which shield them from assuming responsibility, which leads the child to thinking they are incompetent which leads to increased sensitivity to ideas of responsibility

4.       Incident involving action or inaction that leads to a serious misfortune to self or other

5.       Incident involving person erroneously assume that their thoughts, action or inactions contributed to a serious misfortune

In addition to these distal factors there are some proximal ones too:

1.       Experience of systematic criticism

2.       Sudden increase in  responsibility

3.       Critical incident involving real or perceived responsibility

Empirical Status

Inflated responsibility is one of the most extensively researched of the cognitive constructs of obsessional states.  It rests  on 4 hypothesis

Hypothesis 1

Inflated responsibility appraisals are the core feature of all obsessional thinking. Tests show a strong correlation of this for people with compulsive cleaning and checking but less so with people with intrusive thoughts around sex and aggression.  Indeed inflated responsibility only seems active around certain negative events, not positive events.  So whilst OCD clients overall have a high level of belief in inflated responsibility, it is situationally active, and it doesn’t apply to all OCD subtypes.

Hypothesis 2

Inflated responsibility for harm is a distinct cognitive construct that is specific to obsessional thinking.  Here is seems that inflated responsibility is most strongly linked to compulsive checking and contamination.

Hypothesis 3

It is hypothesised that higher perceived levels of responsibility will lead to an increased urge to neutralise heightened discomfort.  Whilst some manipulation of responsibility showed the tests outcome, it was seen as hard to manipulate the responsibility for compulsive cleaners. What did come up is there was a correlation between inflated responsibility and perfectionism.  So where this leaves us is that is it perfectionism, or the estimation of threat as opposed to inflated responsibility that leads to the compulsions

Hypothesis 4

The neutralisation of an obsession will result in an increase in the frequency and salience of an obsession

Ranchman’s misinterpretation of significance theory

Description of the model

Rachman asserts that a normal intrusive thought is misinterpretation as a personally important and threatening phenomenon.  As with Salvoskis intrusive thoughts are seen as an everyday experience that turn into an obsession through misinterpretation.

Misinterpretation of significance

The misinterpretation involves that the intrusive thought is an indicator about one’s character that could lead to very negative consequences:

1.       Losing control

2.       Harming others

3.       Acting violently

4.       Making mistakes

5.       Causing accidents, sickness or injury

Pure avoidance can sometimes manage obsessional thoughts and no compulsions are seen. So pure external avoidance and no internal avoidance.

Rachman cites misinterpretation of significance in 5 dimensions

1.       Importance: the intrusion is seen as meaningful

2.       Personalised: the significance of my thought is that it is of particular importance to me

3.       Ego-Alien: the content of the thought is dystonic

4.       Potential consequences: the thought is seen to be leading to action\consequences no matter how unlikely

5.       Serious consequences: the thought will lead to serious consequences

A  thought will only become obsessional when the intrusive thought is contrary to some very strongly held beliefs, so highly religious, blasphemous intrusion.; People are more likely to make catastrophic misinterpretation of thoughts when they are depressed.

Frequency and persistence of intrusive thoughts

Rachman cites two factors. Firstly the increase in personal significance, the higher the ego dystonic  factor then the greater number of neutral stimuli will be trigger  distressing  thoughts.  Secondly internal factors of anxiety, can trigger intrusive thoughts such as I’m losing control, I’m going mad etc.  The obsession takes hold as avoidance and compulsions prevent disconfirmation of the perceived catastrophic consequences of the obsession.  Lack of control over ones obsessions is misinterpreted as therefore I have no control over my actions.  Again the level of anxiety is interpreted to mean that there is something significant and to be feared about the intrusion, that they have significance.

Other cognitive processes

TAF clients see the thought and action as morally equivalent or that the thought makes the action more likely.  Two types of TAF, probability TAF if I think it it becomes more likely to happen and moral TAF that to think something has the same moral significance as doing it.  Having a TAF aspect is a significant factor in someone’s ability to develop OCD. Inflated responsibility may be both a cause and effect of TAF.

Neutralisation

Neutralisation is defined as an attempt to put right or cancel an obsession, or prevent an obsessions negative outcome happening.  Neutralisation or safety behaviour says because my feared belief is true therefore I need to do x, thus it repeats the belief in x repeatedly  Again thought control is seen as an aspect of neutralisation, where the intrusive thought happens and neutralisation of thought control is used and fails and paradoxically has the enhancement and rebound effect, therefore increasing the intensity and frequency of the thought. ,

Cognitive vulnerability

Rachman notices that OCD clients show catastrophic misinterpretation when faced with ego dystonic thoughts. The pathways to this are considered to be:

1.       Moral perfectionism

2.       Pre-existing cognitive beliefs and biases, e.g. immoral thoughts are as bad as immoral actions

3.       Depression, this may increase the tendency to heightened negative evaluations of events

4.       High trait anxiety, i.e. high anxiety proneness. People who react with anxiety to a wide range of stimuli, will experience more intrusive thoughts

Cognitive theory of compulsive checking

Rachman proposes that  individuals perceive a heighted sense of responsibility to prevent harm but are unsure if they have adequately prevented harm.  However complete certainty that something hasn’t happened , or won’t happen is impossible. Checking behaviour temporarily reduces anxiety but again it reinforces the belief that underpins it. Checking repeatedly reduces the confidence in any individual check, the concomitant anxiety also clouds the mind so that memory is impaired.  Again because they are more focussed on the emotional reaction and the threat again they remember less the detail of their checking which reduces the impact of the check.  Checking increases the sense of personal responsibility by showing you must do something to prevent the feared outcome, I am personally responsible.  Checking again will increase the level of perceived probability of the feared outcome.

The treatment for checking is to

1.       Challenge the belief that one has a special responsibility to protect oneself from harm

2.       Change the misinterpretation of ones checking behaviour, that it prevents harm,

3.       Change the understanding of poor memory, i.e. that it means that you aren’t safe as you can’t remember

Empirical Status

Hypothesis 1

Ranchman’s key hypothesis is that there is  a catastrophic misinterpretation of personal responsibility involving threat.  Research suggests that the level of significance of an intrusive thought is correlated to the extent of ego-dystonia.  There is empirical evidence that OCD clients overestimate the probability and effect of negative events and are consequently lower risk taking individuals.  However some research has shown that it is the perceived ability to cope that is most significant in the development of OC D symptoms and not the perceived probability of threat.

Hypothesis 2

Rachmon hypothesised that certain cognitive biases are indicative of OCD symptoms, so TAF and inflated responsibility.  TAF seems to have a strong correlation with religiosity. TAF probability generally tends to have a stronger correlation with OCD than does TAF morality, with the exception of blasphemous intrusive ego dystonic thoughts.

Summary

Misinterpretation of significance is significant with the development of OCD although it can also be seen in other disorders.  TAF again is significant in OCD but then it is also present within GAD.

The obsessissive compulsive cognitions working group

Description of the model

The group clarified three terms:

1.       Intrusion

a.       Unwanted thoughts\images that intrude into consciousness are called intrusions when they reach clinical severity

2.       Appraisal

a.       Are the interpretation of the meaning of intrusions

3.       Assumptions

a.       Relatively enduring beliefs that are pan situational

Six  belief domains of OCD

1.       Inflated responsibility

a.       That one can prevent negative outcome

2.       Overimportance of thoughts

a.       The mere presence of a thought indicates that it is important

3.       Overestimation of threat

4.       Importance of controlling thoughts

5.       Intolerance of uncertainty

6.       Perfectionism

a.       Belief that there is a perfect solution to every problem and deviance from this can have serious consequences

Empirical status

Intolerance of uncertainty and the need for thought controls seemed to have some specificity to OCD.