Wednesday, 9 January 2019

The Psychology of Obsessive Compulsive Disorder – A Simple Model of OCD

Over recent years Obsessive Compulsive Disorder (OCD) has received popular exposure through TV and social media. This has however contributed to the idea that OCD is a quirky inconvenience or humorous eccentricity. The fact is that this couldn’t be further from the truth. OCD is a highly debilitating anxiety condition which can lead to profound suffering and reduced quality of life.

In this article I will briefly outline what OCD is, how it is maintained and how to best treat the problem. To find out more about OCD you can visit our OCD page at https://thinkcbt.com/ocd-cbt-treatment.

What is OCD?

OCD is a highly distressing anxiety related condition affecting around 1.2% of the general population. In the UK this equates to around 750,000 people. OCD is now clustered together with other Obsessive Compulsive related disorders including Body Dysmorphic Disorder, Trichotillomania, Hoarding Disorder and Excoriation Disorder.

How Does OCD Work?

OCD can be divided into three processes. Firstly, intrusive negative thoughts or disturbing images, sometimes referred to as Egodystonic intrusions.  Secondly, repetitive negative obsessions including ruminations, worry and self-doubting and thirdly, repetitive behaviours or neutralising rituals referred to as compulsions.



The negative intrusive thoughts are often perceived as personally repugnant and are highly distressing. The obsessions cause rumination, worry and self-doubt leading to feelings of anxiety, shame, disgust and depressed mood. The neutralising behaviours or rituals are accepted as irrational but highly habit forming and incredibly difficult to break.

When the individual is triggered by a negative intrusive thought, image or memory, this initiates the obsessional thinking process. The sufferer experiences intense worry or self-doubt leading to high levels of emotional distress. The Compulsion is then used to undo or neutralise the obsessional anxiety.

Over time, this process can become engrained and automatic. Long-term OCD sufferers are often aware of the compulsive element without being consciously aware of the intrusive thought or obsession. The compulsion gradually becomes a reflexive process for controlling or avoiding anxiety. The way to uncover the originating intrusive thoughts and obsessions behind the compulsive behaviour, is to explore the implications of not performing the behaviour or ritual. This can have important implications for the application of ERP, outlined later in this article.

The Role of Operant Learning and Conditioned Responses

There are two important psychological processes at play between the obsessions and compulsions in the maintenance of OCD and this has important implications for effective treatment.

The first process is based on Operant Learning and is referred to as negative reinforcement. The compulsion or neutralising habit provides immediate relief from the obsessional anxiety. This  relief is “negatively reinforced” as it helps take the distress or discomfort away. In behavioural terms, if the relief is greater than the loss experienced by performing the compulsion, the compulsive behaviour will continue. This explains why OCD sufferers logically understand the futility of the compulsion, but still struggle to stop the compulsive behaviour.

The second important psychological process is based on Classical Conditioning and is known as a Conditioned Response. This means that the three OCD components of the intrusion, the obsession and the compulsive behaviour are associated in an automatic chain reaction. Again, OCD suffers fully appreciate the irrationality of their obsessions and behaviours, however the conditioned response makes it extremely difficult to break this engrained and automatic association.

The combined effects of negative reinforcement and the conditioned response make the OCD process highly addictive and incredibly difficult to break. The sufferer is often torn between logically understanding the OCD, yet emotionally feeling compelled to perform the compulsions to dial down their uncertainty and anxiety.

Effective Treatments

The most effective researched treatment for OCD is Cognitive Behavioural Therapy. A number of specific CBT processes have been found to be highly effective in breaking the addictive OCD cycle.

These processes include cognitive reappraisal of obsessional worry and self-doubt, Exposure Response prevention, something called cognitive defusion, a new approach known as Inference Based Therapy and guided behavioural work on personal values. Whilst each of these approaches require specialist support from a trained Cognitive Behavioural Psychotherapist, some key points are briefly outlined below:

Cognitive Reappraisal – this involves psychoeducation and skills training to teach the client how to catch, check and change obsessional worry and self-doubts. The client is taught how to identify, test and intercept negative patterns of thinking that super-charge the intrusion and lead to the need to perform the compulsion.

Whilst cognitive reappraisal has an important part to play in understanding and challenging irrational obsessions, it can inadvertently reinforce the OCD struggle if not supported correctly by a trained CBT specialist. Struggling with obsessional thoughts, even when the struggle is positive, can still ratchet up the obsessional process and contribute to increased attention on the worry or self-doubt.

Exposure Response Prevention – ERP is the longest established and most well researched approach to the treatment of OCD. It primarily involves teaching the client how to minimise, suspend, interrupt or prevent the compulsion. Whilst traditional ERP uses Classical Conditioning principles to habituate the anxiety response, it is also likely to involve a process known as Inhibitory Learning, where the client overlearns and challenges assumptions about their inability to cope with the implications of not performing compulsions.

It is important that traditional ERP is applied on an integrated basis involving graded exposure and behavioural experiments. If ERP is applied as a blunt instrument, it can leave the client feeling overwhelmed and contribute to high drop out rates.

Another angle on ERP is Exposure Relevant to Purpose. This engages the client in altering rather than stopping behaviour and is based on a special form of CBT known as Acceptance and Commitment Therapy. This is briefly outlined in the section covering values below.

Cognitive Defusion – This is one of the six core processes in Acceptance and Commitment Therapy also known as ACT. ACT itself has been found to be highly effective in the treatment of OCD as it teaches clients to disengage from and normalise their obsessional worries an self-doubts. Cognitive Defusion helps the client to see thoughts as thoughts, rather than facts or evidence.

Cognitive Defusion is normally supported by mindfulness practice, work on acceptance and values based action.

Values – Traditional OCD treatments focus on a preventative or remedial approach to OCD, helping the client to move away from distressing thoughts and unhelpful behaviours. This “away from” approach can inadvertently set the client up for failure and emphasise the struggle that characterises OCD itself.

Values based action, is drawn from the ACT model and encourages the client to “move towards” their personal life commitments. It encourages empowerment and asks the client to exercise flexibility and choice when confronted by their distressing thoughts and worries.

This involves identifying compelling reasons to change behaviour that provide greater levels of positive reinforcement than the relief normally associated with performing the compulsion.

Inference Based Therapy – This is a relatively new form of Cognitive Therapy with relevance to OCD related problems. IBT works on the premise that OCD is maintained by patterns of personal self-doubt. Clients are taught how to alter the impact of self-doubts by identifying the difference between inverse inferences and observable facts. IBT helps clients to distinguish between normal doubts and obsessional doubts, so that compulsions become less relevant and unnecessary.

How to Organise Effective OCD Therapy

OCD is a complex problem with many different manifestations. Modern treatment for OCD involves a mix of advanced Cognitive and Behavioural approaches which are most effectively treated with the support of a properly trained and BABCP accredited Cognitive Behavioural Psychotherapist. Always check that your psychologist, Psychotherapist or Counsellor is properly accredited with the British Association of Behavioural and Cognitive Psychotherapy. This will help to ensure that you are working with a competent CBT specialist in the first instance.

The next step is to check that your CBT specialist has experience working with OCD and that they have additional specialist training including ERP, ACT or IBT. This will help to ensure that you are exposed to a combination of effective evidence based techniques to support the specific aspects of the OCD presentation.

For more information about the different forms of OCD you can visit our OCD page at https://thinkcbt.com/ocd-cbt-treatment. You can also contact us by emailing info@thinkcbt.com

William Phillips is a qualified and BABCP accredited Cognitive Behavioural Psychotherapist with specialist interests in OCD-related problems. To find out more about William, you can visit his profile page at https://thinkcbt.com/team/william-phillips.

You can also access free CBT resources and online assessments by visiting our website at https://thinkcbt.com.

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