According to the classification by the American Psychiatric Association (APA) (2002), OCD belongs to the group of anxiety disorders, alongside phobias (specific, social and agoraphobia), generalized anxiety, panic and posttraumatic stress. The DSM V (2013) changed this and OCD was classified as an obsessive-compulsive related disorder.
In truth, both definitions are fitting. Either way we categorise it, OCD’s fundamental feature is the existence of recurring obsessions and/or compulsions that consume time and lead to significant difficulty and distress in a variety of contexts (social, professional, family, and affective) in the life of the sufferer.
OCD is often called "the secret disorder" because symptoms - that may appear from childhood, often go unnoticed or unrecognized by parents and others. When unusual behaviours are observed, many either justify them or react so strongly that frustrated family members or peers often tolerate or enable the behaviours to avoid conflict. However, as OCD is a chronic condition, it is only likely to get worse without appropriate treatment.
In OCD, the obsessions correspond to urges, thoughts, impulses or persistent images which are experienced as intrusive and inappropriate and cause accentuated anxiety and suffering (APA, 2013). They materialize in a person’s mind in a repetitive and stereotypical way, even though the person may recognize them as being unnecessary, irrational or absurd.
As for the compulsions, they are the behavioural counterpart to the obsessions and manifest themselves as an extreme need to act in accordance with a series of repetitive actions in order to avoid or prevent the threats contained in the obsessions.
For example, the idea that if one won’t wash their hands they may infect themselves and their family with a serious illness (obsession) may lead to a relentless need to wash hands in boiling water and lots of soap to ensure no germs survive (compulsion).
Compulsions may present themselves in a number of ways such as the excessive washing of hands or objects, excessive checking of things (doors, windows, gas, etc.), a perfectionist attitude (the task of making each detail in a project absolutely perfect), praying, counting or repeating numbers and words in silence, hoarding or saving up things that are not in actual need and more.
In addition to the devastating consequences that the disorder brings to the life of the sufferer, OCD also usually interferes with family life. The family is often obliged to accommodate itself to the symptoms, by altering their routines and having restrictions as to the use of spaces and objects.
The seriousness of OCD is also related to the sufferer’s insight into their own obsessive-compulsive symptoms, i.e. the ability that a person has to evaluate their own mental state, including self-awareness and the recognition of a clinical condition and the need for treatment. Clearly, the greater the client’s ability for insight, the better their prognosis, as they can share more of their own patterns of thought and behaviour in therapy.
Years ago, OCD was regarded as one of the least treatable illnesses. However, over the last four decades, it all changed, with the development of cognitive-behavioural therapy (CBT) used in combination with Exposure and Response Prevention (ERP).
The Behavioural model of OCD
According to this model, OCD symptoms are the result of a process which takes place in two stages: Acquisition and Maintenance. The first stage, acquisition, occurs by way of classical conditioning where a neutral stimulus (e.g., public toilet, door handle, colours, numbers, thoughts or images) is repeatedly paired with an unconditioned stimulus (fear, anxiety, revulsion), acquire the same properties of the unconditioned stimulus and thus begins to provoke the responses of fear and anxiety. In the second stage, maintenance is developed through negative reinforcement, i.e. where the individual learns to associate their compulsion (ritual, avoidance etc.) they manage to reduce their emotional discomfort (anxiety, fear), albeit temporarily.
ERP therapy was the first highly effective treatment for OCD, the theory being based on the behavioural model of OCD. The main concept that underpins ERP therapy consists of the understanding that all compulsions essentially aim to mitigate risk and danger; where the compulsions are perceived as ‘useful’ (by preventing the chances of risk of anticipated aversive consequence), the only way to eliminate them would be via a reality check. Therefore, it is through the verification of the reality, that catastrophic consequences do not actually follow, that the individual can let go of their use of compulsive / risk-mitigating responses. For this test to occur, the individual needs to be exposed to the situation they fear and prevent the use of compulsion that they would normally use to eliminate the perceived danger that would follow.
Despite the success of ERP therapy, with time it became clear that ERP was not effective in certain cases. For example, patients with a high degree of obsessive thoughts, or with very rigid beliefs around the safety and protection they associated with maintaining the OCD symptoms, seemed to benefit less from ERP and at times would not finish treatment. Given these findings, greater attention began being given to thought patterns and to the cognitive model of OCD.
The Cognitive model of OCD
According to this model, unpleasant, intrusive thoughts (obsessions) are experienced by the majority of people in the population at large. However, most people regard them as unpleasant and meaningless, as being “mental waste”, with no great implication or impact on their lives. Some studies suggest that these “commonplace” intrusions are transformed into obsessions when they cause a high level of emotional distress, as the obsessions are evaluated as personally important, antisocial or immoral, or represent a threat for which the individual feels personally responsible.
The main beliefs present in OCD are related to exacerbation of risk, exaggerated responsibility, intolerance to uncertainty, perfectionism and exaggerated importance attached to thoughts and the need to control them. Therefore, by the cognitive model, when the modification of distorted beliefs is achieved, there will be a reduction in the fear and anxiety associated with the obsessions.
Unfortunately, this model does not explain the motives for which many people carry out rituals without the existence of some cognitions (obsession), present in individuals who like to organize objects symmetrically or who carry out their activities in a particular sequence etc.
However, the Cognitive-Behavioural Treatment (CBT) for OCD brought together the cognitive and behavioural models of OCD and their respective techniques, quickly becoming the most recommended for OCD and achieving the greatest empirical support.
The cognitive-behavioural treatment of OCD is based on a structured process which is brief and to the point. The aim is to reduce the obsessions and compulsion (OCD symptoms) and break down the factors which perpetuate risk-averse behaviours and avoidance.
The therapeutic process can be divided into four stages: Assessment, psychoeducation, intervention (CBT, ERP and Modelling), and relapse prevention. Psychoeducation is a determining factor in CBT. In the case of OCD, besides providing information about cognitive-behavioural treatment, it aims to help the patient recognise their OCD symptoms to develop greater insight and self-awareness.
The ERP exercises and the modelling have a determining role in the cognitive-behavioural treatment of OCD. The ERP exercises are structured on the basis of identifying and listing compulsive symptoms (including in what is considered to be Pure-O, Pure obsessions; the compulsions are less overt, as they are often subliminal, internal, but always exist). This stage enables the production of a hierarchy of activities to which the patient will have to expose themselves to A) test their beliefs and B) develop a more adaptable level of coping with emotional discomfort. These exercises can be carried out both during the session and as homework.
Modelling is found to be a highly effective preceding stage for patients practising ERP. Modelling refers to the therapist conducting ERP exercises in which the patient is possibly fearful of trying, to test the outcome. It is obviously demonstrated in the presence of the patient and was found that the simple observation of other people undertaking tasks considered risky is one way to reduce fear.
Cognitive techniques are introduced into the OCD treatment later on, preferably when the client already has a good understanding of the obsessive-compulsive symptoms and once the ERP exercises have been initiated.
The final stage of treatment is Relapse prevention, in which the patient and the therapist review the treatment stages and interventions that the patient found most useful, ensure any potential barriers to continued work are discussed and addressed, that the patient has easy access to any materials should they wish to review them again, and agree on a long-term plan for the maintenance of the progress that was achieved.
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