OCD

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MODEL -

CBT Model of OCD, outlined by Salkovskis et al (2000) who suggested assumptions and core beliefs form from early experiences and critical distressing life events. These underlying beliefs about the world lead to the occurrence of intrusions, which can be thoughts, images, urges or doubts. Intrusions are common in most people however (Rachman & de Silva, 1978), it is the interpretation of the intrusion that is key to the initiation and maintenance of OCD. Interpretations and beliefs regarding a feeling of inflated responsibility is also key to OCD specifically, compared to other disorders. This is a feeling that the person has the power to prevent/bring about crucial negative outcomes. When compared to other anxiety disorders, OCD patients were more likely to endorse responsibility beliefs about their life (Salkovskis, 2000), believing that things that happened in the world could be controlled and prevented by their thoughts and actions. They also were found to make responsibility related appraisals of intrusions (Salkovskis, 2000), suggesting that they believed intrusive thoughts could be prevented from coming true by performing neutralising actions. Indeed, the CBT model accounts for these factors suggesting that inflated responsibility coupled with thought action fusion, which is the belief that if they have the thought, they must act on it leads to neutralising actions to prevent the behaviour.

However, these rituals, reassurance seeking and obsessive thoughts are mostly not linked to the negative thought in any rational way. For example, a patient might have the thought, "if I don't tap these lamps at least 10 times before bed, then they'll set on fire", leading to ritualistic tapping of the lamps. Rituals such as these will often become impossible, the CBT approach suggests that individuals often have attention and reasoning biases so that their compulsions must fulfil a certain set of criteria to be accepted. This can be laden onto family members in the form of reassurance seeking as well, causing them additional distress. Reassurance seeking is an interpersonal checking behaviour that involves the patient asking someone close to them for reassurance in completing a ritual or behaviour. Reasoning biases mean the family member must fulfil a stringent criterion in order for the behaviour to be accepted, such as looking them directly in the eye the whole time and taking it seriously (Halldorsson et al, 2016). Sometimes patients will attempt to ignore or avoid the intrusive thoughts by suppressing their thoughts and giving themselves impossible criteria that if they achieve, they believe the thoughts will stop. Evidence of 'the rebound effect' Clark et al (1991) suggests that thought suppression leads to the thoughts and subsequent behaviours occurring more frequently after the period of suppression is over. Therefore this is not a productive way to deal with symptoms and can exacerbate their condition. Finally, another key component of the CBT model is mood changes such as distress, anxiety and depression, all of which can have a knock on impact, negatively affecting cognitive appraisals of intrusions and subsequent behaviour to try and "feel better".

TREATMENT -

CBT treatment looks to target the misinterpretations of intrusions by challenging their validity. One strand of CBT known as Exposure and Ritual Prevention Therapy (ERP), is thought to be highly effective in doing this. Based on the 2-factor theory of fear, it suggests that if the neutralising actions OCD sufferers perform to deal with their intrusive thoughts are successful in preventing their thought from coming true, they will be performed in future due to positive reinforcement of the behaviour. Therefore, to undo the belief that the action successfully prevents their thought, individuals must prevent from engaging in these neutralising actions to see if their thoughts are true. ERP treatment focuses on this theory, featuring three key components.

PSYCHOEDUCATION - individuals are taught about the CBT model in regards to how their thoughts and behaviour are linked.

RATING - participants rate situations that they are afraid will lead to bad consequences from easy to hard on a 1-100 scale usually

BEHAVIOURAL EXPERIMENTS - patients perform feared behaviours - could include 'not checking something' or 'touching the edge of a dirty coffee cup' for example. The consequences are then observed and belief in the thought leading to certain consequences is re-rated, showing how their beliefs have changed. Refraining from engaging in the behaviour should disconfirm their dysfunctional belief leading anxiety to diminish via 'extinction'.

One argument against the CBT approach is that OCD is due to neural deficits, in particular to the basal ganglia. Traumatic injury to the basal ganglia can lead to OCD (Jenike, 1986), and compulsions are thought to arise from a failure to inhibit behaviours via the basal ganglia pathway (Baxter et al, 2000). The issue with this theory is that biological treatment is needed to treat this biological cause, so CBT may not be effective as it focuses on changing thoughts alone. Indeed, tricyclics have been found to influence the persistency and frequency of compulsive rituals (Holagen et al, 1998). Yet, there is evidence CBT can 'repair' the brain via challenging of thoughts as it allows individuals to reorganise their beliefs, which may produce different functional connections. In fact, a meta review of neural data regarding OCD found that pathways between the basal ganglia and limbic cortex improved following CBT treatment, and these changes were related to changes in improved symptoms (Schwartz, 1997). Therefore drugs may not be necessary to restructure warped regions of the brain. In fact it was found in a meta-analysis of the effectiveness of treatment on OCD, that CBT produced larger improvements in OCD than drugs (Abramowitz, Whiteside & Deacon, 2005). This may be because drugs act to treat the symptoms rather than the cause, and therefore are not a long term solution.

The interlinking of the CBT model has been displayed in treatment as changing thoughts not only influences behaviour, but has been shown to reduce thought suppression too (Rassin et al, 2001).

However, talking therapies in genera may be helpful to improving the clients condition as it allows them to alleviate the underlying issues that have led to the development of their OCD. Yet cognitive treatments specifically are thought to be the most effective - a more recent review found that both ERP, and traditional CBT which focuses less on the behavioural experiments, were the most efficacious psychological treatments for OCD (Ponniah, Magiah & Hollon, 2013). Additionally, Intensive CBT has been found to immediately cause neural changes, Freyer et al (2011) found that intensive CBT in OCD patients but not controls led to increased activity in the caudate nucleus of patients over time, and improvements in symptoms as assessed by the Yale Brown Obsessive Compulsive Scale was accompanied by greater stability in the palladium. This demonstrates clearly how CBT can target long term neurological change in its methods.

However these results should be reviewed with caution by practitioners. Some individuals will not respond to CBT as effectively, with a certain amount of compliance required to get them to complete tasks they greatly fear, especially if their intrusive thoughts are strongly believed.