Problems with intrusive thoughts, obsessional
worry or doubt and compulsive checking behaviours, are normally strong clinical
indicators for Obsessive Compulsive Disorder (OCD). On this page you can learn about OCD, explore the different OCD subtypes and find out what causes OCD to develop.
In spite of the confusing
and often contradictory information available on the web, the recommended treatment
of choice for OCD spectrum related problems is Cognitive Behavioural Therapy
(CBT).
In addition to mainstream CBT, special forms
of Cognitive Behavioural Therapy known as Acceptance and Commitment Therapy
(ACT), Metacognitive Therapy and Inference Based Therapy have been found to be
particularly effective in the treatment of OCD. Exposure Response and
Prevention (ERP) also forms an integral part of the CBT treatment process,
providing a well established behavioural strategy for reducing OCD compulsions.
We specialise in Obsessive Compulsive
Disorder and all recognised OCD subtypes. This includes contamination OCD, harm
and checking OCD, primarily obsessional OCD, orderliness and symmetry OCD and
the related problem of compulsive hoarding.
We are fully qualified and professionally
accredited by the British Association for Behavioural and Cognitive
Psychotherapy - BABCP, which is the recognised UK professional body for
Cognitive Behavioural Therapy. To talk
to one of our OCD specialists, email
Our specialist OCD treatments are led and supervised by William Phillips, our Principal Psychotherapist. In addition to his work at GoodCBT.com, William consults with a number of other private clinics and provides clinical supervision to other Psychologists and Cognitive Behavioural Psychotherapists. You can
learn more about William here.
Obsessive Compulsive Disorder – OCD is a
clinically recognised psychological disorder in which individuals experience
intrusive thoughts, images or
sensations, obsessional worries or doubts and compulsive checking, neutralising
or reassurance seeking behaviours.
Obsessions are defined as unwanted or intrusive thoughts, urges, feelings
or images, that lead to significant anxiety, distress, discomfort, disgust, as
well as other evaluative feelings including shame, guilt, embarrassment and insecurity.
More recently, another feeling of
“incompleteness” has been identified. This is an emotional sense that things
are not “just right” or “just so”, leaving an unaddressed sense of disorder, indefiniteness,
uncertainty or agitation. This is linked to “Just So” OCD which is described in
more detail below.
The word “Obsession” is derived from the Latin “Obsidere” which means to besiege
or occupy. In our clinical experience working with Obsessive Compulsive
Disorder over many years, this term accurately describes the overwhelming and besieging
feelings experienced by OCD sufferers.
Compulsions are repetitive behaviours or routines that are performed in
an attempt to avoid, neutralise, control or prevent the feared consequences of
the obsession. Whilst compulsions can become automatic over time, they are
generally voluntary actions taken in response to the obsessional doubt or the associated
distress.
Compulsions are normally classified as external and internal. External behaviours sometimes referred to as “Overt” compulsions.
These typically include physical acts such as touching objects, excessive cleaning,
repetitive checking of switches or locks and organising items in a particular order
or sequence.
Internal compulsions, sometimes referred to as “Covert” compulsions
usually involve internal mental acts, rituals or routines. These can include
repeating words or numbers, thought stopping or control, using words or phrases
to neutralise or cancel out fears, excessive praying and repetitive memory
checking.
For a clinical diagnosis of OCD to be present, the individual would
normally experience obsessions and compulsions for at least one hour per day, leading
to significant emotional distress.
If you want to organise a brief informal call to discuss OCD related symptoms, you can send a confidential email to
Whilst the research demonstrates that the
different forms of Obsessive Compulsive Disorder follow a common psychological
pattern, there are specific characteristics relevant to different OCD presentations.
These different forms of OCD are not diagnostically unique, however the content and focus of OCD can vary depending on the individual's history, perceived vulnerabilities and situation. We have outlined ten
common OCD themes below, however it should be noted that the content and focus of obsessions and compulsions can shift like an “OCD Carousel".
Contamination based OCD involving obsessional worry about germs and other forms of physical or mental contamination. This can be linked to health obsessions and frequently leads to superstitious or magical thinking, excessive checking and cleaning behaviours.
Harm based OCD involving intrusive or disturbing thoughts about causing or being responsible for preventing harm to others. This frequently involves highly distressing worry, self-doubt and patterns of avoidance and reassurance seeking behaviours. This can also include specific worry about harm or danger to children.
Primarily Obsessional OCD, also referred to as Pure “O”. This is mainly an internal mentalised form of OCD involving excessive worry, rumination and self-doubt. Whilst it is commonly assumed that this form of OCD does not involve compulsions, Pure “O” also includes internal attempts to stop, avoid, neutralise or control obsessional thoughts. The OCD compulsions still exist, but in an internalised form.
Relationship OCD involves excessive worry and doubt about relationship commitment and compatibility. Like other OCD presentations, the individual’s attachment experiences and irrational beliefs about relationships can profoundly influence ROCD obsessions and compulsive behaviours. ROCD frequently leads to relationship difficulties and breakups, causing significant distress for the sufferer and their partner. Find our more about ROCD here
Real event OCD has more recently been used to describe obsessional worry and rumination about past events or memories. This can involve an obsessional fixation with past mistakes, or continuous attempts to replay, interrogate or test memories. In addition to high levels of anxiety, real-event OCD can be linked to guild or shame and significantly influenced by early maladaptive schema or personal rules and beliefs.
Sensorimotor and hyperawareness OCD are a physicalised form of Obsessive Compulsive Disorder. Sensorimotor typically involves an obsessional focus on body sensations or physiological functions and hyperawareness OCD is linked to testing external senses such as sounds, visual stimuli or smells. Hyperawareness OCD can also be confused with hyperacusis and Misophonia, so it’s important to obtain an accurate diagnosis and treatment.
Scrupulosity OCD involves obsessional worry about sins and violations of religious or moral rules. As worry is focused on faith or ethical issues, the obsessions are impossible to test or disprove , leading to excessive praying, mental or physical purification, reassurance seeking and acts of self-sacrifice to neutralise the worry.
Sexuality OCD involves worry and self-doubt about one’s sexuality or attraction to others outside the individual’s known sexual preferences. This frequently involves self-checking and worry about arousal.
Orderliness and Symmetry OCD, also known as “Just So” OCD involves anxiety and discomfort when things are out of sequence, symmetry or balance. This is characterised by intrusive and obsessional thoughts about disorder and compulsive arranging, organising or visual alignment behaviours.
Existential OCD is similar in nature to Scrupulosity OCD and involves obsessional thoughts about theoretical, hypothetical or philosophical questions that cannot possibly be answered. This frequently involves attempts to disprove or figure out doubts about consciousness, life, meaning or existence itself.
Magical Thinking OCD involves intrusive and obsessional thoughts about superstitious or fatalistic worries and compulsive behaviours in an attempt to prevent or neutralise future possible harm, negative events or bad luck.
Pedophilia OCD also known as POCD, involves obsessional worry avoidance, checking and reassurance seeking behaviours relating to worries about being attracted to children. This is a highly distressing form of OCD linked to repugnant intrusive doubts about the shame and stigma of opposite and inappropriate attraction.
Contemporary
research has identified a number of genetic, neurobiological, environmental,
cognitive and behavioural factors involved in the development and maintenance
of OCD symptoms.
The
research indicates that whilst some genetic and biological differences may
exist, cognitive and behavioural factors are known to directly influence OCD
brain function through the processes of normalization and neuroplasticity.
This means
that whilst the direct causes of OCD are difficult to pin down, changing
thinking and behavioural patterns directly alters the brain structures that
maintain OCD symptoms.
OCD Precursors
and Developmental Risks
Whilst the causes
of OCD are complex, we have summarized some of the contemporary research on the
precursors and developmental risk factors that may contribute to OCD symptoms.
Genetics
and Heritability
Genetics is
thought to play a potential role in developing a vulnerability to OCD. 25%of
Individuals with OCD have another family member with OCD symptoms. Research
into twin studies also shows that identical twins have a statistically higher
prevalence than non-identical twins, indicating the potential role of shared
genetic risk factors. DNA studies may also point to a variation in the
serotonin transporter gene (HSERT), which may explain differences in inhibitory
brain functions. Overall, the research does not point to a direct genetic cause
of OCD, but indicates that genetic differences may be a risk factor or
vulnerability in the development of OCD. Genetics do not cause OCD, but may make
individuals more susceptible to future triggers, traumas or environmental
factors.
Brain Function
and Neurobiology
Neurobiological
factors are complex and not fully understood. Research has however identified a
problem with an important feedback loop between the Orbital Frontal Cortex, the
Basal Ganglia and the Thalamus. This is referred to as the Cortical-striatal–Thalamic-cortical
loop (CSTC). This loop has two modes, a direct activation or excitability
function and an indirect inhibitory or self-regulating function.
Increased
activity in the Orbital Frontal Cortex is associated with the assessment of
potential dangers or concerns, as well as decision making and reward responses.
When the
Orbital Frontal Cortex is activated, it communicates with the Basal Ganglia
causing activation of the direct pathway leading to action to alleviate the
perceived threat or concern.
In healthy
individuals, this is followed by activation of the indirect inhibitory pathway,
returning attention and behaviour to a normal state.
In OCD,
however, the direct pathway is over excitable, dominating the inhibitory or
self-regulatory function of the indirect pathway.
This explains why individuals
with OCD experience difficulties shifting focus and changing behaviour in
response to perceived threats or problems.
Overactivity
in this brain circuit has been found to be “neuroplastic”, causing structural
and architectural changes in this and other associated areas of the brain over
time.
The key
point to note, is that these brain functions are not static. The interaction of
changes in behaviour, cognition and the corresponding neuroplastic changes in
the brain means that the OCD brain circuitry can also be normalised through the
process of inhibitory learning in specialist CBT treatments.
Neurotransmitters
Neurotransmitters
and brain biochemistry also play a part in the maintenance of OCD symptoms. Whilst
the neurochemical pathways are complex, the serotonin, dopamine, Glutamate and Gamma-aminobutric
Acid (GABA), activation and inhibition relationships can be out of balance.
Research into
the biochemical factors in OCD indicates over activity in the Dopamine and
Glutamate systems in the frontal-striatal pathways and diminished activity in
the Serotonin and GABA pathways in the frontal-limbic system. This contributes to over-activation of excitatory pathways
and under-performance of the inhibitory functions
leading to problems with decision making, behaviour and emotional regulation.
These neurochemical imbalances have been identified in individuals with OCD
symptoms.
As with
changes in brain structures and functioning, these complex neurochemical
imbalances can be altered by changes in behaviour, cognition and the use of psychotropic
medications.
PANDAS and
PANS
Pediatric Autoimmune
Neuropsychiatric Disorder Associated with Streptococcus (PANDAS ) develops suddenly
in response to a childhood infection and often causes the immediate onset of
OCD and tic related symptoms. This is caused by the child’s immune system attacking
the basal ganglia in the brain rather than the streptococcal or related infection. This in turn affects
the function of the CSTC brain circuit leading to OCD and other compulsive
behaviours. PANDAS and PANS can be effectively targeted and treated using a
combination of antibiotic medication and Cognitive Behavioural Therapy. It is
crucial that CBT is delivered by a qualified pediatric therapist.
Stress and
Trauma
Whilst some
psychotherapy models including psychodynamic and psychoanalytic therapy emphasise
the important of unresolved trauma and early life experiences in the
development of OCD, there is no evidence to show that trauma and stress cause
OCD itself.
It is
however likely that trauma and other environmental factors may act as a
trigger, which when combined with genetic and biological vulnerabilities, lead
to the development of OCD symptoms.
Cognitive
and Behavioural Causes
Whilst the
cause and affect mechanisms that maintain OCD involve complex interactions
between biological and psychological factors, the fundamental role of behaviour
and cognitive processes in the development and maintenance of OCD is well
documented.
This means
that the way that we act and think in response to perceived difficulties and
threats, is hardwired to our neurological and biochemical brain functions
through the process of neuroplasticity. Altering behaviour and cognition directly
changes the feelings, perceptions and physiological reactions associated with
OCD symptoms.
Cognitive
Behavioural Therapy strategies including Exposure and Response Prevention (ERP),Cognitive
Reappraisal, Metacognitive Therapy, Inference Based Therapy (IBT) and
Acceptance and Commitment Therapy (ACT),
directly undermine and alter the patterns that lead to OCD.
The
research shows that approximately 75% of individuals undertaking CBT, reach
clinical recovery and go on to live normal healthy lives.
To organise a free initial call to discuss specialist Cognitive Behavioural Therapy for OCD, you can complete our contact form or email
In our
section on the causes of Obsessive Compulsive Disorder, we outlined the different factors that
predispose, trigger and maintain OCD symptoms. Whilst there are complex
interactions between neurobiological, environmental, cognitive and behavioural
factors, it is important to recognize that OCD is a psychological disorder, not
a “medical” disease, injury or disability.
As OCD
symptoms are mediated and altered by changes in behaviour and cognition, it’s
therefore important that psychological therapy targets the thinking and behavioural
patterns that maintain the problem.
What Works
and
What Works and What Doesn’t Work?
The
National Institute of Health and Clinical Excellence (NICE), recommends
Cognitive Behavioural Therapy as the first line treatment for Obsessive
Compulsive Disorder. SSRI medication is also recommended as a stand-alone
treatment or adjunct to CBT. Where SSRI medications are ineffective for some
individuals, other medications including Neuroleptics can be prescribed usually
by a psychiatrist.
Talking
therapies including Psychodynamic, Psychoanalytic, existential, Interpersonal
counselling, NLP, The Human Givens approach and other “complementary” therapies
are inappropriate treatments for OCD.
Mainstream
Cognitive Behavioural Therapy (including ERP and cognitive reappraisal),
Metacognitive Therapy, Acceptance and Commitment Therapy and Inference Based Therapy have been found to
provide highly effective treatments for Obsessive Compulsive Disorder. These
therapies can provide recovery rates in excess
of 75%. These approaches are briefly outlined below:
Cognitive
Behavioural Therapy (CBT)
A number of
evidence based Cognitive Behavioural Therapy protocols have been developed over
the last 40 years or so. In addition to Exposure and Response Prevention (ERP),
which is normally integrated into most CBT models, cognitive factors play a
critical role in the treatment of OCD symptoms.
Cognitive is
an umbrella term used to describe the content and processes of thinking including
beliefs, rules, assumptions, perceptions, distortions and attentional biases.
These cognitive factors play a major role in the maintenance of OCD.
The behavioural
aspects of CBT treatment usually involve systematic exposure and behavioural
change to encourage habituation, normalization and a process known as Inhibitory
Learning.
In CBT, cognitive
and behavioural strategies are combined to help clients reappraise and
normalise intrusive and obsessional thoughts, whilst breaking down and
eliminating compulsive behaviours and patterns of avoidance.
Experienced
Cognitive Behavioural Psychotherapists should normally be familiar with the
work of psychological luminaries such as Clarke, Purdon, Rachman, Salkovskis, Wilhelm
& Steketee, Wells and Veale. These names can provide a helpful check-list
when talking to potential therapists about their knowledge and approach.
Metacognitive
Therapy
This
approach was developed by Adrian Wells in 2009 and involves strategies to
target the cognitive processes involved in the interpretation, monitoring and control
of OCD thoughts.
In OCD the concept
is that intrusive thoughts activate “Metacognitive Knowledge”, which includes
beliefs about the individual’s thoughts and thinking processes. This in turn activates
maladaptive cognitive processing such as excessive worry, leading to high
levels of distress and compulsive checking or avoidance behaviours.
In OCD
individuals become entangled in the internal interpretation of their thoughts,
what this might mean and the intensive processes of worry, rumination and doubt
In
Metacognitive Therapy, the focus is on evaluating and altering these internal processes
of thinking rather than externally testing the content of thoughts themselves.
MCT
strategies are aimed at helping clients to update and reinterpret their “Metacognitive
Knowledge” and modify their metacognitive control strategies so that they can view
their thoughts from a less threatening and more realistic perspective.
Experienced
CBT specialists will have a strong knowledge of the Metacognitive model and the
ability to help their OCD clients to identify and change the internal maladaptive
thinking processes that maintain the OCD.
Inference Based
Therapy
Inference
Based Therapy(IBT) was specifically developed for the treatment of Obsessive
Compulsive Disorder and primarily involves a cognitive based approach.
IBT primarily
focuses on the process of inferential confusion, which leads to an
overinvestment in remote possibilities at the cost of externally verifiable
data or the individual’s own common sense.
Inference
Based Therapy makes the distinction between external testable doubt and
internal OCD-related doubts, which are internally generated aspects of the individual’s
own imagination.
The client
is first taught how to identify and describe the internal thinking “devices” responsible
for maintaining the OCD narrative. They are then encouraged to test and compare
this against their external common sensical observations, which they are
finally supported to act upon.
The IBT
protocol shares some conceptual similarities with other process based forms of
CBT and can be used by a skilled OCD specialist either as a distinct treatment
protocol or on an integrated basis.
Acceptance
and Commitment Therapy
Acceptance
and Commitment Therapy (ACT) is another process based approach to CBT, which
has also been found to be highly effective in the treatment of OCD and other
related psychological disorders.
The main
approach in ACT is to treat OCD thoughts as thoughts rather than literal
interpretations or facts, to reduce emotional resistance and to encourage
meaningful action.
Clients are
encouraged to flexibly draw on six core processes involving improved present
moment attention, acceptance, cognitive defusion, perspective taking, personal
values and committed action.
Clients learn
how to shift attention to the now, reduce the struggle with distressing
feelings such as anxiety or disgust, to unhook from or “deliteralise” intrusions
and obsessions , to alter their perspective on the nature of OCD beliefs and to
act in the service of their personal values over their OCD vulnerabilities.
ACT is
focused on improving psychological flexibility in the service of engaging in a
more purposeful life, rather than trying to avoid or control what we fear.
The ACT treatment
approach for OCD can be delivered on an individual basis or integrated alongside
other strategies including ERP, cognitive reappraisal and metacognitive therapy.
In all of
the above approaches, there is a fine balance between drawing on a variety of
tools and techniques and maintaining a clear and straight forward treatment
plan. An experienced OCD therapist can integrate different evidence based
approaches to create and deliver a tailored treatment plan to meet the specific
needs of their client.
Always work with a BABCP accredited CBT
specialist with expertise in the treatment of OCD and related disorders.
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