Obsessive-compulsive disorder (OCD) is a complex disorder that can significantly affect patients’ quality of life. However, with effective therapeutic approaches, such as cognitive behavioral therapy (CBT), it is possible to significantly alleviate symptoms and improve functioning for OCD sufferers. In this article, we take a closer look at how CBT helps treat obsessive-compulsive disorder.
What is obsessive-compulsive disorder?
Obsessive-compulsive disorder OCD is characterized by persistent, recurring thoughts (obsessions) and compulsive behaviors (compulsions). Obsessions are unwanted, intrusive thoughts, imaginings or impulses that cause significant distress. Compulsions, on the other hand, are repetitive behaviors or mental activities that a person feels compelled to perform in response to obsessions or according to strict rules.
ICD 11 diagnosis of obsessive-compulsive disorder
According to the ICD-11 classification, to diagnose OCD, symptoms must:
- Occur on most days for at least 2 weeks.
- Symptoms are repetitive and unpleasant, with persistent obsessions and/or compulsions.
- Obsessions and compulsions take up a significant amount of time (e.g., more than an hour a day) and cause marked discomfort and impede daily functioning.
It is noteworthy that people with OCD are usually aware of the irrationality of their fears and behaviors, but are nevertheless unable to minimize their impact. It is this realization that often causes additional suffering.
Subtypes of obsessive-compulsive disorder in the ICD-11
The ICD-11 distinguishes the following subtypes of OCD:
- 6B20.0 Obsessive-compulsive disorder with good or moderate insight
- 6B20.1 Obsessive-compulsive disorder with poor insight
- 6B20.Z Obsessive-compulsive disorder, unspecified
Cognitive-behavioral model of OCD
Cognitive-behavioral therapy is based on the idea that how we think about a situation affects our emotions and behavior. In the case of OCD, misinterpretations of intrusive thoughts and dysfunctional beliefs are key.
According to the cognitive model of OCD, developed by researchers such as Salkovskis and Rachman, the key elements are:
- Intrusive thoughts, which themselves are a normal phenomenon experienced by most people.
- Misinterpretation of these thoughts. People with OCD attribute undue importance to these thoughts and treat them as threatening.
- Heightened sense of responsibility – OCD patients’ belief that they have the power and responsibility to prevent negative events.
- Thoughtcontrol beliefs – the belief that one should and can control all one’s thoughts.
- Overestimation of danger – a tendency to exaggerate the likelihood and consequences of negative events.
- Intolerance of uncertainty – a strong need for 100% certainty and difficulty in accepting even minimal risks.
These dysfunctional beliefs lead to increasing anxiety in the face of intrusive thoughts. As a result, the person engages in compulsive behaviors (rituals) that temporarily reduce anxiety. In the long term, however, the compulsions reinforce the belief that they must be performed and maintain the vicious cycle of OCD.
The patient – a case study
To more easily illustrate the cognitive-behavioral model of OCD I’ll give you an example of a patient who struggled with obsessive thoughts and compulsions regarding her fear of pollution.
The patient’s story
Anna, a 34-year-old woman, came to therapy because of worsening symptoms of obsessive-compulsive disorder, related to cleanliness and fear of potential illnesses. Anna is married and the mother of two children aged 5 and 7. She works as an elementary school teacher.
Main symptoms
- Obsessive thoughts about the possibility of infecting the family with a dangerous disease.
- Compulsive behavior including excessive hand washing (up to 30 times a day) and disinfecting objects in the home (she spent up to 4 hours a day doing this).
- Avoiding touching “potentially contaminated” surfaces in public places.
- Constantly seeking assurances from family that they are healthy.
History of symptoms
Anna noticed her first OCD symptoms about two years ago, shortly after the birth of her second child. Initially, the symptoms were mild, but over time they worsened, especially during periods of stress. Over the past 6 months, her symptoms have significantly affected her daily functioning, causing problems in her work and family relationships.
Beliefs and thoughts
- “If I don’t do everything in my power to prevent illness, I will be to blame if someone gets sick,” she said
- “Even the slightest contact with germs can lead to a deadly disease.”
- “I should be able to control all my thoughts about illness.”
Impact on life
- Difficulty in performing professional duties due to constant hand washing.
- Reduction in family social activities due to fear of contamination.
- Tensions in the marriage due to time spent on rituals and the constant search for reassurance.
- Feelings of guilt and shame related to the impact of symptoms on family life.
Course of therapy
- Psychoeducation about the nature of OCD and the mechanisms that maintain the symptoms.
- Exposure and response reframing (E/PR):
- Gradual exposure to “dirty” objects, starting with touching things in the office.
- Refraining from washing hands for increasingly long periods after exposure.
- Cognitive restructuring:
- Identifying and modifying dysfunctional beliefs.
- Analysis of evidence for and against catastrophic thoughts.
- Behavioral experiments:
- Intentionally “contaminating” hands in a public place and observing the consequences.
- Cognitive techniques:
- Normalization of intrusive thoughts.
- Analyzing the real probability of contracting the disease.
- Questioning excessive responsibility.
Results of treatment
After 4 months of intensive CBT therapy, Anna achieved significant improvement:
- Time spent on rituals decreased from 3 hours a day to less than 30 minutes.
- Anxiety related to potential contamination decreased significantly.
- Professional and family functioning improved.
- Anna learned strategies for dealing with thought intrusions without resorting to compulsions.
Conclusions
Central to Anna’s therapy was her understanding of the mechanisms that sustain her symptoms and learning new ways to respond to intrusive thoughts. Although Anna still experiences intrusive thoughts at times, she has learned to view them as mere thoughts rather than facts that require an immediate response.
Cognitive-behavioral therapy techniques for treating OCD
CBT for treating OCD uses a number of techniques that aim to change dysfunctional thinking and behavioral patterns. Here are the most important of these:
Exposure and Response Restraint (E/PR)
This is a key behavioral technique in the treatment of OCD. It involves:
- Exposure (E) – gradually and controlled exposure of the patient to situations that trigger obsessions and anxiety.
- Response Restraint (PR) – refraining from performing compulsions in response to anxiety.
The goal of E/PR is habituation, i.e., becoming accustomed to anxiety stimuli and learning that anxiety subsides on its own, even without performing rituals. Exposure can be conducted in reality or in imagination, depending on the nature of the symptoms.
Example: A patient obsessed with contamination may be asked to touch a “dirty” object (exposure) and refrain from washing his hands for a specified period of time (response inhibition).
Cognitive restructuring
This technique focuses on identifying and modifying dysfunctional beliefs underlying OCD. It includes:
- Identification of automatic thoughts and deeper beliefs
- Analyzing the evidence for and against these beliefs
- Developing more adaptive, alternative interpretations
Example: A patient with the thought “If I think about something bad, it will happen,” learns to recognize that it is only a thought, not a fact, and seeks evidence to challenge the belief.
Behavioral experiments
These are planned activities designed to test the accuracy of a patient’s beliefs in reality. They help gather evidence to challenge dysfunctional beliefs and build new, more adaptive cognitive patterns.
Example: A patient deliberately thinks about a negative event and then observes whether it will actually happen, thus learning that thoughts do not have magical causal power.
Cognitive techniques
These include a range of methods to modify the interpretations made by the patient in response to intrusive thoughts. The goal is for the patient to understand that thoughts themselves are not dangerous and do not necessarily lead to action.
Examples of techniques:
- Normalization of intrusive thoughts.
- Analysis of the probability and consequences of the event under discussion.
- Downward arrow technique (uncovering deeper beliefs).
- Questioning excessive responsibility.
Psychoeducation
An important part of therapy is to educate the patient about the nature of OCD, the mechanisms that sustain the symptoms and the principles of therapy. This helps the patient better understand his or her experience and increases motivation for treatment.
Effectiveness of CBT in the treatment of OCD
Numerous studies confirm the effectiveness of cognitive-behavioral therapy in treating obsessive-compulsive disorder. CBT, especially using exposure and response inhibition techniques, is considered the first choice therapy for treating OCD in both adults and children and adolescents.
Studies indicate that about 60-80% of patients achieve significant improvement after using CBT. What’s more, the effects of the therapy are sustained over the long term, and patients learn strategies they can use on their own when symptoms recur.
It is worth noting that cognitive-behavioral therapy can be used both as monotherapy and in combination with pharmacotherapy, especially for more severe forms of OCD.
Summary
Cognitive-behavioral therapy is an effective tool in the treatment of obsessive-compulsive disorder. Through a combination of behavioral techniques, such as exposure and response inhibition, and cognitive techniques, such as cognitive restructuring, CBT helps patients understand and change the patterns of thinking and behavior that sustain OCD symptoms.
Central to the therapy is the understanding that intrusive thoughts themselves are not the problem – it’s the way we interpret and react to them that leads to the development and maintenance of OCD. With CBT, patients learn new, healthier ways to deal with intrusions, leading to symptom reduction and improved quality of life.
While OCD therapy can be challenging for patients, the results are well worth the effort. For many OCD sufferers, cognitive-behavioral therapy opens the way to regaining control of their lives and freeing themselves from limiting symptoms.
Bibliography:
A.Bryńska, Obsessive-compulsive disorder, Warsaw 2007.
Edna B. Foa , Elna Yadin , Tracey K. Lichner. OBSESSIVE-COMPULSIVE DISORDER. Exposure and response inhibition therapy, Gdansk 2021.