Table of Contents

About the Author

Title
Copyright
Preface
Acknowledgments
Dedication
Table of Contents
1 Description
1.1 Terminology
1.2 Definition
1.2.1 Insight
1.3 Epidemiology
1.4 Course and Prognosis
1.5 Differential Diagnoses
1.5.1 Generalized Anxiety Disorder (GAD)
1.5.2 Depression
1.5.3 Tics and Tourette’s Syndrome (TS)
1.5.4 Delusional Disorders (e.g., Schizophrenia)
1.5.5 Impulse Control Disorders
1.5.6 Obsessive Compulsive Personality Disorder (OCPD)
1.5.7 Hypochondriasis
1.5.8 Body Dysmorphic Disorder (BDD)
1.6 Comorbidities
1.7 Diagnostic Procedures and Documentation
1.7.1 Structured Diagnostic Interviews
1.7.2 Semi-Structured Symptom Interviews
1.7.3 Self-Report Inventories
1.7.4 Documenting Changes in Symptom Levels
2 Theories and Models
2.1 Neuropsychiatric Theories
2.1.1 Neurochemical Theories
2.1.2 Neuroanatomical Theories
2.2 Psychological Theories
2.2.1 Learning Theory
2.2.2 Cognitive Deficit Models
2.2.3 Contemporary Cognitive-Behavioral Models
3 Diagnosis and Treatment Indications
3.1 Form Versus Function
3.2 The Diagnostic Assessment
3.3 Identifying the Appropriate Treatment
3.3.1 Empirically Supported Treatments for OCD
3.4 Factors that Influence Treatment Decisions
3.4.1 Age
3.4.2 Gender
3.4.3 Race
3.4.4 Educational Level
3.4.5 Patient Preference
3.4.6 Social Support
3.4.7 Clinical Presentation
3.4.8 OCD Symptom Theme
3.4.9 Insight
3.4.10 Comorbidity
3.4.11 Treatment History
3.5 Presenting the Recommendation for CBT
4 Treatment
4.1 Methods of Treatment
4.1.1 Functional Assessment
4.1.2 Self-Monitoring
4.1.3 Psychoeducation
4.1.4 Using Cognitive Therapy Techniques
4.1.5 Planning for Exposure and Response Prevention
4.1.6 Implementing Exposure and Response Prevention
4.1.7 Ending Treatment
4.2 Mechanisms of Action
4.3 Efficacy and Prognosis
4.4 Variations and Combinations of Methods
4.4.1 Variants of CBT Treatment Procedures
4.4.2 Combining Medication and CBT
4.5 Problems in Carrying out the Treatment
4.5.1 Negative Reactions to the CBT Model
4.5.2 Nonadherence
4.5.3 Arguments
4.5.4 Therapist’s Inclination to Challenge the Obsession
4.5.5 When Cognitive Interventions Become Rituals
4.5.6 Unbearable Anxiety Levels During Exposure
4.5.7 Absence of Anxiety During Exposure
4.5.8 Therapist Discomfort with Conducting Exposure Exercises
5 Case Vignettes
6 Further Reading
7 References
8 Appendix: Tools and Resources
Obsessive-Compulsive Disorder
About the Author
Jonathan S. Abramowitz, PhD, is Associate Professor and director of the OCD/Anxiety
Disorders Program at the Mayo Clinic. He has written or edited four books and over 75
research articles and book chapters on OCD and other anxiety disorders. For his
contributions to the field, Dr. Abramowitz has received awards from the American
Psychological Association and the Mayo Clinic.
Advances in Psychotherapy – Evidence-Based Practice
Danny Wedding; PhD, MPH, Prof., St. Louis, MO (Series Editor)
Larry Beutler; PhD, Prof., Palo Alto, CA
Kenneth E. Freedland; PhD, Prof., St. Louis, MO
Linda C. Sobell; PhD, ABPP, Prof., Ft. Lauderdale, FL
David A. Wolfe; PhD, Prof., Toronto (Associate Editors)
The basic objective of this new series is to provide therapists with practical, evidence-
based treatment guidance for the most common disorders seen in clinical practice – and
to do so in a “reader-friendly” manner. Each book in the series is both a compact “how-
to-do” reference on a particular disorder for use by professional clinicians in their daily
work, as well as an ideal educational resource for students and for practice-oriented
continuing education.
The most important feature of the books is that they are practical and “reader-friendly”:
All are structured similarly and all provide a compact and easy-to-follow guide to all
aspects that are relevant in real-life practice. Tables, boxed clinical “pearls”, marginal
notes, and summary boxes assist orientation, while checklists provide tools for use in
daily practice.
Obsessive-Compulsive Disorder
Jonathan S. Abramowitz
Mayo Clinic, OCD/Anxiety Disorders Program, Rochester, MN
Library of Congress Cataloging in Publication
is available via the Library of Congress Marc Database under the LC Control Number 2005936094
Library and Archives Canada Cataloguing in Publication
Abramowitz, Jonathan S
Obsessive compulsive disorder / Jonathan S. Abramowitz.
(Advances in psychotherapy--evidence-based practice)
Includes bibliographical references.
ISBN 0-88937-316-7
1. Obsessive-compulsive disorder. 2. Obsessive-compulsive disorder—Treatment. I. Title. II. Series.
RC533.A27 2005a 616.85›227 C2005-906627-X
© 2006 by Mayo Foundation for Medical Education and Research
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Preface
This book describes the conceptualization, assessment, and psychological treatment of
obsessive-compulsive disorder (OCD) using the empirically supported cognitive-
behavioral therapy procedures of exposure, response prevention, and cognitive
therapy. The development of effective problemfocused treatments for psychological
disorders such as OCD has created an enormous need for the dissemination of
treatment programs, such as this one, to mental health professionals who want to know
how to use such techniques with their patients. This book builds upon psychological
principles of behavior change. As such, it assumes basic knowledge and some training in
psychotherapeutic intervention. It is written for psychologists, psychiatrists, social
workers, students and trainees, and other mental health care practitioners. It is
intended not only for those specializing in OCD or other anxiety disorders, but for those
clinicians who wish to learn how to manage OCD effectively in their day-to-day practice.
The book is divided into five chapters. The first chapter describes the clinical
phenomenon of OCD, differentiating it from other disorders with similar characteristics
and outlining empirically supported diagnostic and assessment procedures. Chapter 2
reviews what is known about the leading theoretical models of the development and
maintenance of OCD, and their treatment implications. In Chapter 3, I present a
framework for conducting an initial assessment and for deciding whether a particular
patient is a candidate for the psychological treatment program outlined in Chapter 4.
Methods for explaining the diagnosis of OCD and introducing the treatment program are
incorporated. Chapter 4 presents in detailed fashion the nuts and bolts of effective
psychological treatment techniques for OCD. There are numerous case examples and
transcripts of in-session dialogs to illustrate the treatment procedures. The chapter also
reviews scientific evidence for the efficacy of this program, and describes a number of
common obstacles to successful treatment. Finally, Chapter 5 includes a series of case
examples describing the treatment of various sorts of OCD symptoms (contamination,
fears of responsibility for harm, etc.). A variety of forms and patient handouts for use in
treatment appear in the book’s Appendix.
OCD is a highly heterogeneous disorder. For example, some patients experience fears of
germs and contamination, while others have recurring unwanted anxiety-evoking ideas
of committing heinous acts that they are unlikely to commit (e.g., running into
pedestrians while driving, murdering loved ones). It is rare to see two sufferers with
completely overlapping symptoms. Although a systematic and multicomponent
treatment approach is advocated in this book, this manual is not intended as a
cookbook. Instead, the clinician is guided in tailoring specific treatment components to
individual patients’ needs. This manual provides a practical and structured approach
with supporting didactic materials for both clinicians and patients.
Acknowledgments
I am indebted to a large group of people, including series editor Danny Wedding and
Robert Dimbleby of Hogrefe and Huber, for their invaluable guidance and suggestions.
The pages of this book echo with clinical wisdom I acquired during my pre- and
postdoctoral training at the Center for Treatment and Study of Anxiety in Philadelphia,
where I spent many hours learning about OCD and its treatment from master clinicians
such as Martin Franklin and Michael Kozak, who also took a genuine interest in my
professional development. In addition, I wish to thank my undergraduate and graduate
academic mentors—Kathleen Harring, T. Joel Wade, and Art Houts—for impressing
upon me the importance of science in psychology and psychological practice.
I am also grateful for the support of my wonderful colleagues at Mayo Clinic, including
Stephen Whiteside, Sarah Kalsy, Brett Deacon (now at the University of Wyoming),
Katherine Moore, Stefanie Schwartz (now in private practice in Florida), Kristi Dahlman,
and Jill Snuggerud. I owe a great deal to my remarkably competent secretary, Marcia
Redalen, who oversees my daily schedule and frequently communicates with patients.
This book is dedicated to all of the patients and research participants who have come to
our clinic seeking help and, not knowing what to expect of treatment, found the courage
to confront their fears and defeat their anxiety. They believed in us, confided in us,
challenged us, and educated us.
Most of all, this book would not be possible without the enduring love, support, and
patience of my wife Stacy, and our children, Emily and Miriam. Their affection inspires
me to do my very best every day. With their help, I have gained a clearer sense of who I
am as a person, a father, a husband, and a psychologist.
Dedication
To my parents, Ferne and Les Abramowitz—my only creators
Table of Contents
Preface
Acknowledgments
Dedication

1
1.1
1.2
1.2.1
1.3
1.4
1.5
1.5.1
1.5.2
1.5.3
1.5.4
1.5.5
1.5.6
1.5.7
1.5.8
1.6
1.7
1.7.1
1.7.2
1.7.3
1.7.4

2
2.1
2.1.1
2.1.2
2.2
2.2.1
2.2.2
2.2.3

3
3.1
3.2
3.3
3.3.1
3.4
3.4.1
3.4.2
3.4.3
3.4.4
3.4.5
3.4.6
3.4.7
3.4.8
3.4.9
3.4.10
3.4.11
3.5

4
4.1
4.1.1
4.1.2
4.1.3
4.1.4
4.1.5
4.1.6
4.1.7
4.2
4.3
4.4
4.4.1
4.4.2
4.5
4.5.1
4.5.2
4.5.3
4.5.4
4.5.5
4.5.6
4.5.7
4.5.8
5

8
1
Description
1.1 Terminology
Obsessive-compulsive disorder (OCD) (300.3) was previously known as obsessive-
compulsive neurosis. It is sometimes considered part of a spectrum of conditions
characterized by more or less similar features (see Section 1.5).
1.2 Definition
Definition of obsessions and compulsions
OCD is classified in the DSM-IV-TR (American Psychiatric Association, 2000) as an
anxiety disorder (300.3) defined by the presence of obsessions or compulsions (see
Table 1). Obsessions are persistent intrusive thoughts, ideas, images, impulses, or
doubts that are experienced as unacceptable, senseless, or bizarre and that evoke
subjective distress in the form of anxiety or doubt. Although highly specific to the
individual, obsessions typically concern the following themes: aggression and violence,
responsibility for causing harm (e.g., by mistakes), contamination, sex, religion, the need
for exactness or completeness, and serious illnesses (e.g., cancer). Most patients with
OCD evidence multiple types of obsessions. Examples of common and uncommon
obsessions appear in Table 2.
DSM-IV Diagnostic Criteria for OCD
Table 1
DSM-IV Diagnostic Criteria for OCD
A. Either obsessions or compulsions.
Obsessions are defined by (1), (2), (3), and (4):
(1) repetitive and persistent thoughts, images, or impulses that are experienced, at some point, as
intrusive and inappropriate and that cause marked anxiety or distress
(2) the thoughts, images, or impulses are not worries about real-life problems
(3) the person tries to ignore or suppress the thoughts, images, or impulses, or neutralize them with
some other thought or action
(4) the thoughts, images, or impulses are recognized as a product of one’s own mind and not
imposed from without
Compulsions are defined as (1) and (2):
(1) repetitive behaviors or mental acts that one feels driven to perform in response to an obsession
or according to certain rules
(2) the behaviors or mental acts are aimed at preventing or reducing distress or preventing feared
consequences; however the behaviors or mental acts are clearly excessive or are not connected in a
realistic way with what they are designed to neutralize or prevent
B. At some point during the disorder the person has recognized that the obsessions or compulsions
are excessive or unreasonable.
C. The obsessions or compulsions cause marked distress, are time-consuming (take more than 1
hour a day), or significantly interfere with usual daily functioning.
D. The content of the obsessions or compulsions is not better accounted for by another Axis I
disorder, if present. (e.g., concern with appearance in the presence of body dysmorphic disorder, or
preoccupation with having a serious illness in the presence of hypochondriasis).
E. Symptoms are not due to the direct physiological effects of a substance or a general medical
condition.
Specify if:
With poor insight: if for most of the time the person does not recognize that their obsessions and
compulsions are excessive or unreasonable.
Adapted from the DSM-IV diagnostic criteria for OCD (American Psychiatric Association, 1994, pp.
422–423). Adapted with permission.
Compulsions are urges to perform behavioral or mental rituals to reduce the anxiety or
the probability of harm associated with obsessions. Compulsive rituals are deliberate,
yet clearly senseless or excessive in relation to the obsessional fear they are designed to
neutralize. As with obsessions, rituals are highly patient-specific. Examples of
behavioral (overt) rituals include repetitious hand washing, checking (e.g., locks, the
stove), counting, and repeating routine actions (e.g., going through doorways).
Examples of mental rituals include excessive prayer and using special phrases or
numbers to neutralize obsessional fear. Table 3 presents examples of some common
and uncommon compulsive rituals.
Examples of common and uncommon obsessions
Table 2
Common and Uncommon Obsessions
Common obsessions
– Thoughts of contamination from germs, dirt, fungus, animals, body waste, or household chemicals
– Persistent fears and doubts that one is (or may become) responsible for harm or misfortunes such
– Unacceptable sexual ideas (e.g., molestation)
– Unwanted violent impulses (e.g., to attack a helpless person)
– Unwanted sacrilegious thoughts (e.g., desecrating a synagogue)
– Need for order, symmetry, completeness
– Fears of certain numbers (e.g., 13, 666), colors (e.g., red), or words (e.g., murder)
Uncommon obsessions
– Fear of having an extramarital affair with a stranger by mistake
– Fear of becoming someone else
– Fear of absorbing calories by touching food
– Fear of contamination from a geographic region
Examples of common and uncommon compulsions
Table 3
Common and Uncommon Compulsive Rituals
Common rituals
– Washing one’s hands 50 times per day or taking multiple (lengthy) showers
– Repeatedly cleaning objects or vacuuming the floor
– Returning several times to check that the door is locked
– Placing items in the “correct” order to achieve “balance”
– Re-tracing one’s steps
– Re-reading or re-writing things to prevent mistakes
– Calling relatives or “experts” to ask for reassurance
– Thinking the word “life” to counteract hearing the word “death”
– Repeated and excessive confessing of one’s “sins”
– Repeating a prayer until it is said perfectly
Uncommon rituals
– Repeating oneself to ensure that others understand what has been said
– Having to look at certain points in space in a specified way
– Having to mentally rearrange letters in sentences to spell out comforting words
1.2.1 Insight
Patients vary in terms of their insight into the senseless of their symptoms
Patients with OCD show a range of “insight” into the senselessness of their obsessions
and compulsions—some acknowledge the irrationality of their symptoms while others
are firmly convinced (approaching delusional intensity) that the symptoms are rational.
To accommodate this parameter of the clinical picture of OCD, the diagnostic specifier
“with poor insight” is used to indicate that the patient believes his or her fears and
rituals are reasonable. Often, the degree of insight varies across time and obsessional
themes. For example, a patient might recognize his or her contamination fears as
senseless, yet have poor insight into the irrationality of a fear of causing harm to others.
1.3 Epidemiology
OCD has a one-month prevalence of 1.3% and a lifetime prevalence of 2-3% in the adult
population (this is equivalent to 1 in 40 adults) (Karno, Golding, Sorenson, & Burnam,
1988). The disorder affects men and women in equal numbers, although among
children, boys have a higher prevalence rate than girls.
Despite its relatively high prevalence (OCD is the 4th most common psychological
disorder after depression, substance abuse, and phobias), most individuals with OCD
suffer for several years before they receive adequate diagnosis and treatment. Factors
contributing to the under-recognition of OCD include the failure of patients to disclose
symptoms, the failure to screen for obsessions and compulsions during mental status
examinations, and difficulties with differential diagnoses (see Section 1.5).
1.4 Course and Prognosis
OCD generally runs a chronic and deteriorating course
OCD symptoms typically develop gradually. An exception is the abrupt onset sometimes
observed following pregnancy. The modal age of onset is 6-15 years in males and 20-29
years in females. Generally, OCD has a low rate of spontaneous remission. Left
untreated, the disorder runs a chronic and deteriorating course, although symptoms
may wax and wane in severity over time (often dependent upon levels of psychosocial
stress).
1.5 Differential Diagnoses
OCD is often confused with other disorders with similar features
In clinical practice, OCD can be difficult to differentiate from a number of disorders with
deceptively similar symptom patterns. Moreover, the terms “obsessive” and
“compulsive” are often used indiscriminately to refer to phenomena that are not clinical
obsessions and compulsions as defined by the DSM-IV-TR. This section highlights key
differences between the symptoms of OCD and those of several other disorders.
1.5.1 Generalized Anxiety Disorder (GAD)
Anxious apprehension may be present in both OCD and GAD. However, whereas worries
in GAD concern real-life problems (e.g., finances, relationships), obsessions in OCD
contain senseless or bizarre content that is not about general life problems (e.g., fear of
contracting AIDS from walking into a hospital). Moreover, the content of worries in GAD
may shift frequently, whereas the content of obsessional fears is generally stable over
time.
1.5.2 Depression
OCD and depression both involve repetitive negative thoughts. However, depressive
ruminations are generalized, pessimistic ideas about the self, world, or future (e.g., “no
one likes me”) with frequent shifts in content. Unlike obsessions, ruminations are not
strongly resisted and they do not elicit avoidance or compulsive rituals. Obsessions can
be thoughts, ideas, images, and impulses that involve fears of specific disastrous
consequences with infrequent shifts in content.
1.5.3 Tics and Tourette’s Syndrome (TS)
Both OCD and TS sometimes involve stereotyped or rapid movements. However, tics (as
in TS) are spontaneous acts evoked by a sensory urge. They serve to reduce sensory
tension rather than as an escape from obsessive fear. In contrast, compulsions in OCD
are deliberate acts evoked by affective distress and the urge to reduce fear.
1.5.4 Delusional Disorders (e.g., Schizophrenia)
Both OCD and delusional disorders involve bizarre, senseless, and fixed thoughts and
beliefs. These thoughts might evoke affective distress in both conditions. However,
unlike obsessions, delusions do not lead to compulsive rituals. Schizophrenia is also
accompanied by other negative symptoms of thought disorders (e.g., loosening
associations) that are not present in OCD.
1.5.5 Impulse Control Disorders
Excessive and repetitive behaviors might be present in both OCD and impulse control
disorders such as pathological gambling, pathological shopping/buying,
trichotillomania, kleptomania, compulsive internet use (e.g., viewing pornography) and
“sexual compulsions.” For this reason, impulse control disorders are sometimes
considered part of an “OCD spectrum.” However, the repetitive behaviors in impulse
control disorders are performed to achieve a thrill or rush (i.e., they are impulsive),
whereas compulsive rituals in OCD are performed to escape from distress. Although
individuals with impulse control disorders may experience guilt, shame, and anxiety
associated with their problematic behaviors, their anxiety is not triggered by
obsessional cues as in OCD. Obsessions are not present in impulse control disorders.
1.5.6 Obsessive Compulsive Personality Disorder (OCPD)
Whereas OCD and OCPD have overlapping names, there are more differences than
similarities between the two conditions. OCPD is a set of pervasive traits that involve
rigidity and inflexibility, meticulousness, and sometimes impulsive anger and hostility.
People with OCPD view these traits as functional and therefore consistent with their
world view (i.e., they are “ego-syntonic”). On the other hand, OCD symptoms are
experienced as upsetting and incongruent with the person’s world view (i.e., “ego-
dystonic”). Hence, OCD symptoms are resisted, whereas OCPD symptoms are not.
1.5.7 Hypochondriasis
Persistent thoughts about illnesses and repetitive checking for reassurance can be
present in both OCD and hypochondriasis (sometimes considered an OCD spectrum
disorder). In OCD, however, patients evidence additional obsessive themes (e.g.,
aggression, contamination), whereas in hypochondriasis, patients are singly obsessed
with their health.
1.5.8 Body Dysmorphic Disorder (BDD)
Both BDD (also considered part of an OCD spectrum) and OCD can involve intrusive,
distressing thoughts concerning one’s appearance. Moreover, repeated checking might
be observed in both disorders. However, whereas people with OCD also have other
obsessions, the focus of BDD symptoms is limited to one’s appearance.
1.6 Comorbidities
Comorbidity is common in OCD
Comorbidity with other Axis I disorders is more common in OCD than in other anxiety
disorders. The most frequently co-occurring diagnoses are depressive disorders and
other anxiety disorders. About 50% of people with OCD have experienced at least one
major depressive episode (or dysthymia) in their lives. Commonly co-occurring anxiety
disorders include generalized anxiety disorder, panic disorder, and social phobia, with
rates ranging from 30% to 45% (Crino & Andrews, 1996a). When comorbid depression
is present, OCD typically predates the depressive symptoms, suggesting that depressive
symptoms usually occur in response to the distress and functional impairment
associated with OCD (rather than as a precursor). Depressive symptoms also seem to be
more strongly related to the severity of obsessions than to compulsions. Less
frequently, individuals with OCD have comorbid eating disorders, tic disorders (e.g.,
Tourette’s syndrome), and impulse control disorders.
Axis II (personality) disorders may also co-occur with OCD, although available
prevalence rates have ranged widely (from 8.7% to 87.5%) depending on how the Axis
II psychopathology is assessed. Studies generally agree that personality disorders
belonging to the anxious cluster (e.g., obsessive-compulsive, avoidant) are more
common than those of other clusters (Crino & Andrews, 1996b).
1.7 Diagnostic Procedures and Documentation
This section reviews the empirically established structured and semi-structured
diagnostic interviews and self-report measures for assessing the presence and severity
of OCD symptoms, as well as for documenting changes in these symptoms during a
course of psychological treatment.
1.7.1 Structured Diagnostic Interviews
Two structured diagnostic interviews that are based on DSM-IV-TR criteria can be used
to confirm the diagnosis of OCD and common comorbid disorders: the Anxiety
Disorders Interview Schedule for DSM-IV (ADIS-IV; Di Nardo, Brown, & Barlow,
1994) and the Structured Clinical Interview for DSM-IV (SCID-IV; First, Spitzer,
Gibbon, & Williams, 2002). Both of these instruments possess good reliability and
validity. The SCID is available over the Internet at www.scid4.org, and the ADIS is
available from Oxford University Press.
1.7.2 Semi-Structured Symptom Interviews
OCD is unique among the emotional disorders in that the form and content of its
symptoms can vary widely from one patient to the next. In fact, two individuals with
OCD might present with completely nonoverlapping symptoms. Such heterogeneity
necessitates a thorough assessment of the topography of the patient’s symptoms: what
types of obsessions and compulsions are present and how severe are these symptoms?
Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
The Y-BOCS—a measure of OCD symptom severity
The Y-BOCS (Goodman, Price, Rasmussen, Mazure, Delgado et al., 1989; Goodman, Price,
Rasmussen, Mazure, Fleischmann et al., 1989), which includes a symptom checklist and
a severity rating scale, is ideal for addressing these questions. From 30–60 minutes
might be required to administer this semi-structured interview. A full copy of the
measure appears in the Journal of Clinical Psychiatry, volume 60 (1999), supplement 18,
pages 67–77. The first part of the Y-BOCS Symptom Checklist provides definitions and
examples of obsessions and compulsions that the clinician reads to the patient. Next, the
clinician reviews a list of over 50 common obsessions and compulsions and asks the
patient whether each symptom is currently present or has occurred in the past. Finally,
the most prominent obsessions, compulsions, and OCD-related avoidance behaviors are
listed.
There have been no psychometric studies of the Y-BOCS Checklist, yet clinical
observation suggests that the instrument is quite comprehensive. One limitation is that
it assesses obsessions and compulsions according to form rather than function. It is
therefore up to the clinician to inquire about the relationship between obsessions and
compulsions (i.e., which obsessional thoughts evoke which rituals). A second limitation
is that the checklist contains only one item assessing mental rituals. Thus, the clinician
must probe in a less structured way for the presence of these covert symptoms. The
assessment of mental rituals is discussed further in Section 4.1.1.
The Y-BOCS Severity Scale includes 10 items to assess the following five parameters of
obsessions (items 1–5) and compulsions (items 6–10): (a) time, (b) interference, (c)
distress, (d) efforts to resist, and (e) perceived control. Each item is rated on a scale
from 0 to 4 and the item scores are summed to produce a total score ranging from 0 (no
symptoms) to 40 (extreme). Table 4 shows the clinical breakdown of scores on the Y-
BOCS severity scale. The measure has acceptable reliability, validity, and sensitivity to
change. An advantage of the Y-BOCS is that it assesses OCD symptom severity
independent of symptom content. However, a drawback of this approach is that the
clinician must be cautious to avoid rating the symptoms of other disorders (e.g., GAD,
impulse control disorders) as obsessions or compulsions.
Table 4
Clinical Breakdown of Scores on the Y-BOCS Severity Scale
Y-BOCS score
0–7
8–15
16–23
24–31
32–40
Brown Assessment of Beliefs Scale (BABS)
The BABS—a measure of insight in OCD
Since poor insight has been linked to attenuated treatment outcome, initial assessment
of OCD should include determination of the extent to which the patient perceives his or
her obsessions and compulsions as senselessness and excessive. The BABS (Eisen et al.,
1998) is a semi-structured interview that contains 7 items and assesses insight as a
continuous variable. The patient first identifies one or two current obsessional fears
(e.g., “If I touch dirty laundry without washing my hands, I will become sick”). Next,
individual items assess (a) conviction in this belief, (b) perceptions of how others view
this belief, (c) explanation for why others hold a different view, (d) willingness to
challenge the belief, (e) attempts to disprove the belief, (f) insight into the senselessness
of the belief, and (g) ideas/delusions of reference. Each item is rated on a scale from 0 to
4 and the first six items are summed to obtain a total score of 0 to 24 (higher scores
indicate poorer insight). The seventh item is not included in the total score. The BABS
has good reliability, validity, and sensitivity to change. It is available from Dr. Jane Eisen
at Brown University School of Medicine.
Hamilton Rating Scale for Depression (HRSD)
Because the majority of individuals with OCD also experience depressive symptoms, the
assessment of mood complaints via a semi-structured interview is recommended. The
HRSD (Hamilton, 1960) is a well-studied tool that measures cognitive (e.g., feelings of
guilt), affective (e.g., current mood state), and somatic (e.g., appetite, sleep) aspects of
depression. The scale has adequate psychometric properties and is also sensitive to the
effects of treatment. It is available on the internet at:
http://www.strokecenter.org/trials/scales/hamilton.pdf.
1.7.3 Self-Report Inventories
Self-report inventories are used to gather additional severity data
Psychometrically validated self-report questionnaires can be used to supplement the
clinical interviews described above. Such questionnaires are easily administered,
carefully worded, and have well-established norms. Accordingly, they are best used to
corroborate information obtained from clinical interviewing and to monitor symptom
severity during treatment.
Obsessive Compulsive Inventory—Revised (OCI-R)
The OCI-R—a brief measure of OCD severity
The OCI-R (Foa, Huppert, Leiberg, Langner, Kichic, Hajcak, & Salkovskis, 2002) consists
of 18 items that measure a wide range of obsessive-compulsive symptoms. Each item
(e.g., “I check things more often than necessary”) is rated on a 5-point scale of distress
associated with that particular symptom. The OCI-R has six subscales corresponding to
various presentations of OCD: washing, checking, ordering, obsessing, hoarding, and
neutralizing. Each subscale contains three items which are summed to produce subscale
scores (range = 0–12). A total score (range = 0–72) may be calculated by summing all 18
items. The OCI-R, which is psychometrically sound, is printed in the journal
Psychological Assessment, volume 14 (2002), on page 496.
Beck Depression Inventory (BDI)
The BDI (Beck, Ward, Medelsohn, Mock, & Erlbaugh, 1961) is one of the most widely
used self-report measures of depression. It contains 21-items that assess the cognitive,
affective, and somatic features of global distress. The BDI has good psychometric
properties and is easy to administer and score. Patients typically need from 5 to 10
minutes to complete the scale and scores of 20 or greater usually indicate the presence
of clinical depression. The BDI is available from the Psychological Corporation.
Beck Anxiety Inventory (BAI)
The BAI (Beck, Epstein, Brown & Steer, 1988) is a reliable, valid, and widely used
measure of general anxiety. It consists of 21 items that assess the cognitive,
physiological, and behavioral components of anxiety. The BAI is also available from the
Psychological Corporation.
1.7.4 Documenting Changes in Symptom Levels
Assessing OCD symptoms throughout treatment
Continual assessment of OCD and related symptoms throughout the course of
psychological treatment assists the clinician in evaluating treatment response. It is not
enough to simply assume that “he seems to be less obsessed,” or “it looks like she has
cut down on her compulsions,” or even for the patient to report that he or she now
“feels better.” Periodic assessment and comparison with baseline symptom levels using
psychometrically validated self-report and interview measures should be conducted to
clarify objectively in what ways treatment has been helpful and what work remains to
be done.
2
Theories and Models
A number of theoríes have been proposed to explain the development and clinical
picture of OCD. This chapter reviews several theoretical models that have been well-
studied, with an emphasis on the cognitive-behavioral model which forms the basis of
the treatment program described in Chapter 4.
2.1 Neuropsychiatric Theories
2.1.1 Neurochemical Theories
Neuropsychiatric theories of OCD
Neuropsychiatric theories of OCD can be categorized into neurochemical theories and
neuroanatomical theories. Prevailing neurochemical theories posit that abnormalities in
the serotonin system, particularly the hypersensitivity of postsynaptic serotonergic
receptors, underlie OCD symptoms (Gross, Sasson, Chorpa, & Zohar, 1998). This
“serotonin hypothesis” was proposed following observations that serotonergic
medication, but not other kinds of antidepressants, were effective in reducing OCD
symptoms. However, results from numerous studies that have directly examined the
relationship between serotonin and OCD have been inconsistent. For instance, some
studies report increased concentrations of serotonin metabolites in the cerebrospinal
fluid of OCD patients relative to nonpatients; other studies do not report such findings.
Whereas the preferential response of OCD to serotonergic medication is often
championed as supporting the serotonin hypothesis, this argument is of little value
since the hypothesis was derived from this treatment outcome result. Thus, whether
serotonin functioning mediates OCD symptoms remains unclear.
2.1.2 Neuroanatomical Theories
Predominant neuroanatomical models of OCD propose that obsessions and compulsions
arise from structural and functional abnormalities in particular areas of the brain,
specifically the orbitofrontal-subcortical circuits (Saxena, Bota, & Brody, 2001). These
circuits are thought to connect regions of the brain involved in processing information
with those involved in the initiation of certain behavioral responses; and their
overactivity is thought to lead to OCD. Neuroanatomic models have been derived from
imaging studies in which activity levels in specific brain areas are compared between
OCD patients and healthy controls. For example, positron emission tomography (PET)
studies have consistently found increased glucose utilization in the orbitofrontal cortex
(OFC) among patients with OCD as compared to nonpatients.
Although highly interesting, neuroanatomical studies are cross-sectional and therefore
do not reveal whether OCD is caused by apparent dysfunctions in the brain. It is
possible that the observed alterations in brain function represent normally functioning
brain systems that are affected by having a chronic anxiety disorder such as OCD.
2.2 Psychological Theories
2.2.1 Learning Theory
A learning (conditioning) model
The learning (conditioning) model of OCD is based on the two-factor theory of fear
which proposes that obsessional anxiety is acquired by classical conditioning and
maintained by operant conditioning (Mowrer, 1960). For example, the obsessional fear
of floors is said to arise from a traumatic experience during which anxiety becomes
associated with floors. This fear is then maintained by behaviors that prevent the
natural extinction of the fear, such as avoidance of floors and compulsive washing after
contact with the floor. Avoidance and rituals are also negatively reinforced by the
immediate (albeit temporary) reduction in discomfort that they engender.
Research supports some aspects of the learning theory. For example, obsessional
stimuli (thoughts, ideas, images, and associated stimuli) evoke anxiety, and compulsive
rituals bring about an immediate reduction in anxiety and distress (Rachman, 1980).
However, other features are unsupported. For instance, obsessions do not appear to
develop through classical conditioning (e.g., from traumatic experiences). Thus, the
learning model provides a basis for understanding the persistence of OCD symptoms,
particularly rituals, but does not adequately account for the development of obsessional
fear.
2.2.2 Cognitive Deficit Models
Cognitive deficit models
Compared to nonpatients, people with OCD evidence abnormalities on a range of
cognitive tasks such as executive functioning, cognitive inhibition, and some forms of
memory. However, these deficits are not found in all patients, and even when they are
present, they tend to be mild. Nevertheless, some theorists have suggested that OCD
arises from aberrations in general information processing systems. The deficits are
general in the sense that they affect both neutral and OCD-related information (McNally,
2000).
Cognitive deficit models have two key limitations. First, they do not account for the
heterogeneity of OCD symptoms (e.g., why some patients have contamination
obsessions while others have sexual obsessions). Second, because mild cognitive deficits
are present in many disorders (e.g., panic, bulimia nervosa) these models fail to explain
why such deficits give rise to OCD instead of one of these other disorders. Thus, if
cognitive deficits play a causal role in OCD, they most likely represent a nonspecific
vulnerability factor that might (or might not) contribute to the etiology of obsessions
and compulsions.
2.2.3 Contemporary Cognitive-Behavioral Models
Contemporary cognitive-behavioral models of OCD form the basis for CBT
The treatment program described in this book is based on a cognitive-behavioral
approach in which OCD is thought to arise from specific sorts of dysfunctional beliefs
(Shafran, 2005). Cognitive-behavioral models begin with the well-established finding
that intrusive thoughts (i.e., thoughts, images, and impulses that intrude into
consciousness) are normal experiences that most people have from time to time.
Sometimes triggered by external stimuli (e.g., thoughts of a house fire that are triggered
by the sight of a fire truck), such intrusions usually reflect the person’s current
concerns. Research also shows that people with no history of OCD have intrusive
thoughts about “taboo” topics such as sex, violence, blasphemy, and germs.
The model proposes that normal intrusions develop into highly distressing and time-
consuming clinical obsessions when the intrusions are mistakenly appraised as posing a
threat for which the individual is personally responsible. For example, consider the
unwanted impulse to yell a curse word in a quiet place such as a church or a theatre.
Most people would consider such an intrusive impulse as meaningless and harmless
(e.g., “mental noise”). However, according to the cognitive-behavioral model, such an
intrusion would develop into a clinical obsession if the person attaches to it a high
degree of importance, leading to an escalation in negative emotion—for example,
“Thinking about yelling in church means I’m an immoral person,” or “I must be extra
careful to make sure I don’t lose control.” Such appraisals evoke distress and motivate
the person to try to suppress or neutralize the unwanted thought (e.g., by praying or
replacing it with a “safe” thought), and to attempt to prevent any harmful events
associated with the intrusion (e.g., by avoiding churches).
Factors that maintain obsessional fear
Compulsive rituals are conceptualized as maladaptive efforts to remove intrusions and
to prevent feared consequences. However, there are several ways in which rituals are
counterproductive. First, they are technically “effective” in temporarily providing the
desired reduction in obsessional distress. Therefore, these strategies are negatively
reinforced, and frequently evolve into behavioral patterns that consume substantial
time and effort (i.e., they become “compulsive”) and impair the individual’s ability to
function. Second, because they reduce anxiety in the short term, rituals prevent the
natural abatement of the fear response that typically occurs when individuals stay in
feared situations for longer periods of time. Third, rituals lead to an increase in the
frequency of obsessions by serving as reminders of obsessional intrusions, thereby
triggering their reoccurrence. For example, compulsively checking the stove can trigger
intrusions about house fires. Attempts at distracting oneself from unwanted intrusions
may paradoxically increase the frequency of intrusions, possibly because the distractors
become reminders (retrieval cues) of the intrusions. Finally, performing rituals
preserves dysfunctional beliefs and misinterpretations of obsessional thoughts. That is,
when feared consequences do not occur after performance of a ritual, the person
attributes this to the ritual that was performed.
Table 5
Summary of Maintenance Processes in OCD
Maintenance process
Selective attention
Physiological factors
Safety-seeking behavior
Passive avoidance
Concealment of obsessions
Attempted thought control
Brief summary of the cognitive-behavioral approach to OCD
To summarize, when a person appraises an otherwise normally occurring mental
intrusion as posing a threat for which he or she is responsible, the person becomes
distressed and attempts to remove the intrusion and prevent the feared consequences.
This paradoxically increases the frequency of intrusions. Thus, the intrusions escalate
into persistent and distressing clinical obsessions. Because the obsessional thought is
experienced as distressing, it evokes urges to perform some response—overt or covert
—to neutralize the distress and reduce the probability of a feared outcome.
Compulsions maintain the intrusions and prevent the self-correction of mistaken
(catastrophic) appraisals. Table 5 summarizes the various factors that maintain OCD
symptoms.
Misinterpretations of one’s thoughts might include any appraisal of the intrusive
thought as personally significant or threatening. An example is the belief that thinking
about bad behavior is morally equivalent to performing the corresponding behavior
(e.g., “Thinking about committing adultery is as bad as actually doing it”). An
international group of researchers interested in the cognitive basis of OCD, the
Obsessive Compulsive Cognitions Working Group (OCCWG; Frost & Steketee, 2002)
identified three domains of “core beliefs” thought to underlie the development of
obsessions from normal intrusive thoughts. These are summarized in Table 6. Figure 1
graphically depicts the contemporary cognitive-behavioral conceptual model.
Domains of pathogenic beliefs in OCD
Table 6
Domains of Pathogenic Beliefs in OCD
Belief

Inflated responsibility/Overestimation of threat

Figure 1
Cognitive-behavioral conceptual model of OCD
Implications of the Cognitive-Behavioral Model
Normalizing Effects
The cognitive-behavioral approach assumes no specific brain dysfunction
The cognitive-behavioral approach provides a logically and empirically consistent
account of OCD symptoms that assumes the presence of intact learning (conditioning)
processes and normally functioning (albeit maladaptive) cognitive processes. There is
no appeal to “chemical imbalances” or disease states to explain OCD symptoms. Even
the maladaptive beliefs and assumptions that lead to obsessions are viewed as
“mistakes” rather than “disease processes.” Furthermore, avoidance and safety-seeking
rituals to reduce perceived threat would be considered adaptive if harm was indeed
likely. However, OCD patients’ obsessive fears are exaggerated. Therefore, their
avoidance and safety-seeking rituals are not only irrational, but highly problematic
since they perpetuate a vicious cycle of intrusion → misappraisal → anxiety, and so on.
Vulnerability to OCD
The distal cause of OCD is unknown, but the disorder’s etiology probably involves
interactions among biological, genetic, and environmental variables. Cognitive-
behavioral models propose that certain experiences lead people to develop core beliefs
that underlie OCD. For example, an obsession could develop in someone who was taught
high moral standards and expected to obey rigid and extreme codes of conduct where
the threat of punishment for disobedience was constantly present (e.g., certain religious
doctrines). However, empirical evidence supporting the role of these kinds of
experiences in the etiology of OCD is equivocal.
Treatment Implications of the Model
Treatment implications of the cognitive-behavioral model
The cognitive-behavioral model leads to specific targets for reducing OCD symptoms. In
particular, effective treatment must help patients (a) correct maladaptive beliefs and
appraisals that lead to obsessional fear and (b) decrease avoidance and safety-seeking
behaviors (e.g., rituals) that prevent the self-correction of maladaptive beliefs. In short,
the task of cognitive-behavior therapy (CBT) is to foster an evaluation of obsessional
stimuli as nonthreatening and therefore not demanding of further action. Patients must
come to understand their problem not in terms of the risk of feared consequences, but
in terms of how they are thinking and behaving in response to stimuli that objectively
pose a low risk of harm. Those with aggressive obsessions must view their problem as
lending too much significance to meaningless intrusive thoughts (instead of how they
are going to achieve the ultimate guarantee that feared consequences will not occur).
Patients with washing rituals must see their problem not as needing a sure-fire way to
prevent illness, but as the need to change how they evaluate and respond to situations
that realistically pose a low risk of illness. The treatment procedures outlined in Chapter
4 are derived from the learning and cognitive-behavioral models of OCD, and therefore
address these targets.
3
Diagnosis and Treatment Indications
This chapter provides the clinician with a framework for conducting a diagnostic
assessment and providing consultation regarding treatment for OCD. The cognitive-
behavioral model and its treatment implications (see Chapter 2) determine how
information about the patient’s symptoms is assessed and conceptualized. The initial
consultation provides an excellent opportunity to initiate rapport building and begin
socializing the patient to the cognitive-behavioral approach to OCD.
3.1 Form Versus Function
The cognitive-behavioral model emphasizes functional aspects of OCD symptoms
Whereas the diagnostic criteria for OCD emphasize the form of obsessions and
compulsions (e.g., repetition), the cognitive-behavioral model emphasizes the
functional aspects of these phenomena. From this perspective, the essential features of
OCD are anxiety-evoking obsessional thoughts and anxiety-reducing strategies such
as rituals and avoidance. It is the person’s dysfunctional beliefs and appraisals of
obsessional stimuli which give rise to obsessional fear. Thus, ways in which patients
give meaning to obsessional stimuli must be assessed. Rituals and avoidance are
deliberate attempts to reduce the anxiety evoked by obsessions. Yet whereas
“compulsiveness” and repetition might be the most outwardly observable signs of OCD,
patients actually deploy a variety of escape and avoidance behaviors in response to
obsessional distress, and only some of these tactics (collectively termed “safety
behaviors”) are repetitive or “compulsive”. Table 7 shows the array of safety behaviors
that might be observed in OCD. Clinicians should assess how the patient’s safety
behaviors are related to obsessional stimuli and dysfunctional thinking patterns.
Safety behaviors in OCD
Table 7
Types of Safety Behaviors Observed in OCD
Type
Passive avoidance
Compulsive rituals
Covert neutralizing
Brief or subtle “mini” rituals
Common OCD symptom presentations
Table 8
Common OCD Symptom Presentations
Symptom presentation
Contamination
Harming
Incompleteness
Unacceptable thoughts
Evidence for the functional relationship between obsessions and safety-seeking
behaviors comes from research consistently identifying dimensions of OCD symptoms
that involve specific types of obsessions and safety behaviors (McKay et al., 2004). Table
8 shows the most commonly identified OCD symptom dimensions.
3.2 The Diagnostic Assessment
How to conduct a diagnostic assessment for OCD
The cognitive-behaviorally focused diagnostic interview begins with the patient
providing a general description of his or her problem as well as the reasons for seeking
help. Be sure to ascertain the functional relationship between obsessions and rituals as
described in previous sections. Also, determine the onset, historical course of the
problem, social, developmental, and medical history, and personal/family history of
psychiatric treatment, along with substance use (i.e., drugs, alcohol, tobacco), and
exercise and sleep habits. In addition, assess the treatment history (particularly
treatment for OCD) as this may influence your current recommendations. Once this
information has been obtained, use the Y-BOCS, BABS, HRSD, and various self-report
measures to gather additional severity data.
Two additional self-report instruments, the Obsessional Beliefs Questionnaire (OBQ)
and the Interpretations of Intrusions Inventory (III) (Obsessive Compulsive
Cognitions Working Group, 2003), can be administered to assess OCD-related
dysfunctional beliefs (i.e., those described in Table 6). The OBQ and III are reprinted in
Frost and Steketee’s (2002) edited volume on cognitive aspects of OCD.
When patients report only obsessions or only compulsions
Clinical Pearl
When Patients Report Obsessions or Compulsions in Isolation
Whereas the majority of OCD patients readily describe obsessional fears and compulsive rituals,
some present with complaints of “pure obsessions” or “compulsions without obsessions.” When
assessing such patients, keep in mind that both obsessions and compulsions are present in the vast
majority of people with OCD. Thus, you might need to conduct a more in-depth functional analysis.
For individuals reporting only obsessions, this means inquiring about the use of any anxiety-
reduction strategy (mental rituals or subtle behavioral or cognitive neutralizing or avoidance) that
might be functioning to maintain obsessional fear. Most patients don’t recognize these safety
behaviors as OCD symptoms, but these behaviors maintain obsessional fear just as surely as overt
rituals. If these phenomena are not present, perhaps the “obsessions” are not intrusive or anxiety-
evoking and therefore not indicative of OCD (e.g., perhaps they are depressive ruminations, worries
as in GAD, or other ego-syntonic thoughts).
When patients describe compulsive behaviors but fail to define obsessional fear, inquire about what
triggers these behaviors. If they are not evoked by specific intrusive or distressing thoughts or
situations as described in Chapter 1, OCD might not be the correct diagnosis. Perhaps an impulse-
control (e.g., trichotillomania) or tic disorder is present. You should use the Y-BOCS checklist, self-
report questionnaires, and detailed inquiry regarding the functional aspects of reported symptoms
to rule in or rule out the diagnosis of OCD.
3.3 Identifying the Appropriate Treatment
3.3.1 Empirically Supported Treatments for OCD
Empirically supported treatments for OCD
Currently, two empirically supported treatments exist for OCD: cognitive-behavioral
therapy (CBT) and pharmacotherapy involving serotonin reuptake inhibitor (SRI)
medication. This section briefly describes these treatments and their advantages and
disadvantages.
Medication for OCD
Medication for OCD
Table 9 displays the brand names, generic names, and therapeutic doses of medications
with demonstrated clinical efficacy for OCD. These agents are thought to reduce OCD by
increasing the concentration of serotonin. On average, a 20%–40% improvement in
OCD symptoms over a 12-week period can be expected from treatment with medication.
There are various advantages and disadvantages to using medication for treating OCD,
and these are listed below:
Advantages and disadvantages of medication
Advantages of Medication
• Safe and easy to use
• Clinically effective: 20% to 40% symptom reduction on average
Disadvantages of medication
• Limited improvement rates
• About 50% of people do not improve
• Possibility of side effects
• Must be used continuously in order to sustain any improvement
Medications for OCD
Table 9
Medications with Demonstrated Clinical Efficacy for Treating OCD*
Brand name
Anafranil
Zoloft
Prozac
Luvox
Paxil
Celexa
* At least one double-blind randomized controlled trial exists in which the medication was more effective than a placebo.
Cognitive-Behavior Therapy for OCD
CBT
CBT is based on an understanding of the symptoms of OCD (rather than its putative
causes). Consistent with the cognitive-behavioral model (Chapter 2), OCD is viewed as a
set of maladaptive thinking and behaving patterns that patients must learn to weaken.
The vital components of CBT include (a) education, (b) cognitive therapy techniques, (c)
exposure therapy, and (d) response prevention. These components are briefly
described next.
The psychoeducational component of CBT for OCD entails socializing the patient to the
cognitive-behavioral conceptual model and providing a rationale for how the treatment
techniques are designed to weaken obsessions and compulsions. Cognitive techniques
for OCD involve rational discussion to help the patient identify and correct mistaken
beliefs that underlie obsessional fears, avoidance, and safety-seeking behaviors.
Exposure and response prevention are the centerpiece of CBT
Exposure and response prevention are the centerpiece of the treatment program.
Exposure entails gradually confronting situations and thoughts that evoke obsessive
fear. This is often accompanied by imagining the feared consequences of exposure. For
example, an individual who fears contamination and sickness from garbage cans would
practice touching garbage cans and then imagine coming down with an illness from
“germs.” The procedure requires that the patient remain exposed until the associated
distress decreases on its own, without attempting to reduce the distress by withdrawing
from the situation or by performing compulsive rituals. Thus the response prevention
component of CBT entails refraining from any behaviors (behavioral and mental rituals,
subtle avoidance, and neutralizing strategies) that serve to reduce obsessional anxiety
or terminate exposure. For example, the patient described above would refrain from
any cleaning rituals. Exposure and response prevention provide the patient with
evidence that obsessional fears are irrational and that rituals are not necessary to
prevent disasters or reduce distress.
As with medication treatment, there are advantages and disadvantages to CBT. These
are listed as follows:
Advantages and disadvantages of CBT
Advantages of CBT
• Clinically effective: 60%–70% symptom reduction on average
• Treatment is fairly brief (usually 15 to 20 sessions)
• Long-term maintenance of treatment gains
Disadvantages of CBT
• Patient must work hard to achieve improvement
• Involves purposely evoking anxiety during exposure
• Not widely available
3.4 Factors that Influence Treatment Decisions
Factors that influence decisions about treatment
This section considers factors that influence clinical decisions regarding which type of
treatment to recommend for a particular patient with OCD.
3.4.1 Age
CBT is the treatment of choice for all age groups with OCD. Compared to young and
middle-aged adults, children and the elderly tend to have more difficulty with
adherence to medication. The elderly are more vulnerable to drug side effects due to
reduced metabolic rate and possible interactions with other medicines. Family conflict
can interfere with CBT in children.
3.4.2 Gender
Men and women respond equally well to CBT. However, some patients feel more
comfortable with a therapist of the same sex, especially if sexual or contamination
concerns are present (e.g., fears of touching one’s genitals). A same sex therapist would
also be necessary to accompany patients during exposure to public restrooms.
3.4.3 Race
Some members of minority groups are uncomfortable receiving psychological
treatments and prefer pharmacotherapy over CBT, as the former carries less stigma.
Such individuals might be less willing to report embarrassing symptoms to the therapist
or perform exposure tasks in public settings. Despite these issues, many minority
patients with OCD achieve clinically significant improvement with CBT (Williams,
Chambless, & Steketee, 1998).
3.4.4 Educational Level
Successful CBT requires that the patient grasp a theoretical model of OCD and a
rationale for treatment. Patients must also be able to implement treatment procedures
on their own and consolidate information learned during exposure exercises. These
tasks may be difficult for individuals who are very concrete in their thinking. Medication
is recommended for developmentally disabled and cognitively impaired patients.
3.4.5 Patient Preference
Patient preference should be considered
Preference for a particular treatment modality should be considered. Reviewing the
advantages and disadvantages of each approach allows the patent to make an informed
decision about which therapy they would prefer to receive. Greater adherence to either
treatment (especially CBT) can be expected from patients who agree willingly to a
particular plan, as opposed to those situations in which treatment is forced on them.
3.4.6 Social Support
Although it may be beneficial for patients to identify a relative or close friend to provide
support during CBT, this is not always essential. Such a confidant should be firm,
relaxed, and empathic. Emotionally overinvolved, hostile, and inconsistent people can
lead to treatment attrition. Before enlisting a specific support person to help with CBT,
one should assess how this person interacts with the patient.
3.4.7 Clinical Presentation
CBT targets obsessions and compulsions. Thus, if such symptoms are not primary
complaints, CBT is not recommended. Because CBT requires a substantial commitment,
it should not be initiated when patients are concurrently engaged in therapies likely to
compete for time and energy. Instead, such patients should begin with SRIs until their
schedule can accommodate CBT.
In general, OCD symptom severity should not factor into the decision of whether to treat
patients with medication or CBT. CBT is more effective than medication for any severity
level. However, severe symptoms may require a more intense regimen of whatever
treatment is offered: i.e., a higher dose of medicine or more frequent CBT sessions. If the
patient presents a danger to self or others, inpatient treatment is recommended. Where
possible, however, we recommend CBT be conducted on an outpatient basis to
maximize generalizability of treatment gains to the patient’s own personal
surroundings.
3.4.8 OCD Symptom Theme
Most presentations of OCD respond to CBT and medication
Both CBT and medication can produce improvement across the various presentations of
OCD (e.g., washing, checking). However, these treatments appear less beneficial when
hoarding symptoms predominate the clinical picture (Abramowitz, Franklin, Schwartz,
& Furr, 2003). It also has been suggested that OCD patients with “pure obsessions” (i.e.,
obsessions without overt rituals) fare less well in CBT compared to those displaying
overt compulsive rituals. However, as is described in Chapter 4, exposure and response
prevention can be adapted to successfully treat this presentation of OCD.
3.4.9 Insight
Patients with poor insight into the senselessness of their OCD symptoms show an
attenuated response to CBT due to (a) reluctance to engage in treatment exercises and
(b) difficulty consolidating what is to be learned from repeated exposures. While CBT is
worth attempting, increased use of cognitive therapy techniques might be necessary to
help patients engage in (and benefit from) exposure tasks. Another augmentative
approach is to use medication; some psychiatrists use antipsychotic medication to treat
patients with very poor insight.
3.4.10 Comorbidity
OCD patients with comorbid depression and those with GAD show reduced response to
CBT. Seriously depressed patients become demoralized and have trouble complying
with treatment instructions. Their strong negative affect may also exacerbate OCD
symptoms. In GAD, pervasive worry detracts from patients’ mental resources available
for learning skills in CBT.
Other Axis I conditions likely to interfere with CBT are those that involve alterations in
perception, cognition, and judgment, such as psychotic and manic symptoms. Patients
actively abusing psychoactive substances are also poor CBT candidates. These problems
impede the ability to profit from CBT exercises and can also reduce adherence. Bringing
these comorbid conditions under control is a requirement before beginning CBT.
Both CBT and medication may be adversely affected by severe Axis II psychopathology.
Different personality disorder (PD) clusters may differentially influence the process and
outcome of CBT. Anxious (e.g., OCPD) and dramatic (e.g., histrionic) traits interfere with
rapport development; yet, success is possible if a therapeutic relationship can be
established. Patients with personality traits in the odd cluster (e.g., schizotypy) present
a challenge to CBT due to their reduced ability to consolidate corrective information
from exposure or cognitive interventions.
3.4.11 Treatment History
Patients who have received an adequate dosage of one SRI for a reasonable time (at
least several weeks) are generally unlikely to respond to other SRIs, or to combinations
of SRIs. Thus, for medicated patients who have not had psychological treatment, CBT is
the logical recommendation. If patients report that they have undergone CBT, the
adequacy of this therapy course should be assessed before making additional
recommendations. If treatment sessions were infrequent, or if therapist-guided
exposure and response prevention were not incorporated, a course of adequate CBT
should be considered. On the other hand, a history of adherence problems may suggest
the need for residential treatment or a supportive/interpersonal approach.
3.5 Presenting the Recommendation for CBT
How to recommend CBT to the patient
Once you have determined that a patient is a candidate for CBT, present him or her with
a summary of the assessment results and a rationale for starting treatment. At the
patient’s discretion, members of the patient’s family (e.g., spouse or parent) who can be
counted on to provide support can be included in this discussion. The points below
should be clearly conveyed to the patient during this consultation.
• Review the data collected during the interview which suggest the presence (and
severity level) of OCD.
• Define OCD and review the signs and symptoms as discussed in Section 1.1. Use the
patient’s own symptoms as examples. Emphasize that OCD is a chronic problem that is
unlikely to get better without effective treatment.
• Tell the patient that the exact causes of OCD are unknown. Some research suggests
there is a biological basis (i.e., serotonin irregularities); other research suggests anxiety
problems can be learned. Emphasize that numerous factors (biological and
environmental) probably contribute to the development of OCD.
• Convey that effective treatment does not require that we know the causes, but only
that we understand the symptoms of OCD. Fortunately, after much research, we have
come to understand these symptoms very well.
• Describe medications for OCD, including their advantages and disadvantages, using
the material presented in Section 3.3.1. Explain that medication is based on the
biological model of OCD as a problem with serotonin.
• Describe CBT as a form of treatment that aims to weaken the symptoms of OCD,
regardless of what causes them in the first place. Specifically, CBT aims to weaken two
maladaptive patterns: (a) becoming anxious over obsessional triggers, and (b) using
avoidance and compulsive rituals to reduce anxiety. Give examples of the patient’s
symptoms to illustrate these patterns.
• Using the information in Section 3.3.1 as a guide, describe the procedures of gradual
exposure and response prevention. Inform the patient that these techniques involve
learning skills to weaken the two patterns mentioned above. Provide examples of the
kinds of exposure exercises and response prevention rules that might be used in
treatment.
• Explain that during treatment, the patient can expect to become anxious, but that the
anxiety is temporary and it subsides with practice. During treatment, the therapist will
help the patient learn healthier ways of thinking and responding to anxiety-evoking
situations so that the OCD patterns are weakened.
• Assure the patient that you realize CBT is hard work. Review the advantages and
disadvantages to this approach.
• Use the analogy of the therapist as a coach. You will help the patient to learn and use
skills to reduce OCD. This is accomplished in a collaborative manner. You will never
force (or surprise) the patient with exposure tasks.
• Ensure that the patient understands that how much benefit a person gets from CBT is
related to how much effort they put into doing the treatment.
• Recommend a trial of 16 sessions of CBT and answer any questions from the patient
(and family members).
4
Treatment
4.1 Methods of Treatment
The “nuts and bolts” of conducting CBT
This chapter presents the nuts and bolts of how to plan and implement a CBT program
for OCD. Table 10 shows the optimal schedule for what is to be accomplished in each
treatment session. In our clinic, such a program is delivered in 16 twice-weekly sessions
over an 8-week period (patients traveling from out of town receive 5 daily sessions for 3
consecutive weeks). However, in the interest of flexibility, the focus of this chapter is on
mastery of the particular treatment strategies rather than on promoting a strict
session-by-session agenda.
Suggested session structure in CBT for OCD
Table 10
Suggested Session Structure in Psychological Treatment for OCD
Session 1
– Begin functional assessment of OCD symptoms
– Introduce self-monitoring
– Begin psychoeducation
Session 2
– Continue functional assessment
– Psychoeducation
– Cognitive therapy
– Begin planning for exposure
Session 3
– Psychoeducation
– Cognitive therapy
– Finalize and agree on the exposure treatment plan
Sessions 4–8
– Exposure (progressing up the fear hierarchy)
– Response prevention
– Cognitive therapy
Sessions 9–11
– Exposure (facing the greatest fears)
– Response prevention
– Cognitive therapy
Sessions 12–14
– Exposure (emphasis on patient as his/her own therapist)
– Response prevention
– Cognitive therapy
Sessions 15 & 16
– Final exposures
– End response prevention
– Assess outcome
– Arrange for follow-up care (as necessary)
4.1.1 Functional Assessment
Functional assessment—the collecting of detailed, patient-specific information
Functional assessment is the collection of highly detailed patient-specific information
about obsessional triggers and the cognitive and behavioral responses to these stimuli,
including a complete description of all compulsive rituals (behavioral and mental). The
cognitive-behavioral theory dictates what information is collected and how it is
organized to form a conceptualization of the problem and an effective CBT program. The
Functional Assessment of OCD Symptoms form (see Appendix) is used to document
this information. Depending on the complexity of the patient’s symptoms, this
assessment might last from 1 to 4 hours. Begin by providing a rationale for the detailed
functional assessment that incorporates the following points:
• CBT involves learning skills to weaken OCD symptoms.
• To tailor the program to the patient’s specific obsessions and rituals, you must have a
complete understanding of these symptoms.
• Treatment therefore begins by generating a list of all of the situations and thoughts
that evoke anxiety and urges to do rituals.
Assessing Obsessional Stimuli
Generate a complete list of external triggers and internal stimuli (thoughts) that evoke
obsessional fear. These stimuli might be used as the basis of exposure exercises.
External Triggers
Identify all objects, situations, places, etc. that evoke obsessional fear and urges to
ritualize. Examples include bathrooms, knives, doing paperwork, churches, the number
“13,” leaving the house, driving in certain places, and so on. Examples of questions to
elicit this information include:
• What kinds of situations make you feel anxious?
• What kinds of things do you avoid?
• What triggers you to want to do rituals?
Obsessional Thoughts
In OCD, anxiety is also evoked by recurring ideas, images, doubts, and impulses that the
patient finds upsetting, immoral, repulsive, or otherwise unacceptable. Examples
include thoughts of germs and contamination, impulses to desecrate the church, images
of genitalia, ideas concerning loved ones being injured, doubts about making mistakes,
and impulses to harm innocent people or loved ones. Examples of questions to elicit this
information include:
• What intrusive thoughts do you have that trigger anxiety?
• What thoughts do you try to avoid, resist, or dismiss?
Assessing Cognitive Features
Obtain information about the following parameters of the cognitive basis of the patient’s
fear. This helps in developing effective exposure and cognitive therapy interventions.
Feared Consequences
Identify fears of disastrous consequences
Most patients articulate fears that something terrible will happen if they are exposed to
their obsessional stimuli or if they fail to perform certain rituals. For example, they
would be responsible for injury to a loved one, become ill (if they do not wash), have
bad luck from confronting the number “13,” or make terrible mistakes in paperwork.
Examples of questions to elicit feared consequences include:
• What is the worst thing you imagine happening if you are exposed to (obsessional
trigger)?
• What do you think might happen if you didn’t do your ______ rituals?
Misinterpretations of Obsessional Thoughts
Identify the ways in which the patient misinterprets obsessional thoughts
Identify mistaken beliefs about the presence and meaning of intrusive obsessional
thoughts, impulses, and images. For example, “Thinking about stabbing my wife could
lead me to actually stab her,” “God will punish me for thinking immoral thoughts,” “I’m a
pervert if I have unwanted thoughts about sex,” and “Anyone who thinks gay thoughts
must be gay.” Examples of questions to elicit this information include:
• What do you think it means that you have this thought?
• What will happen if you think this thought too much?
• Why do you try to avoid or dismiss these thoughts?
Fears of Experiencing Long-Term Anxiety
Some patients do not articulate specific feared consequences, but instead worry that anxiety
will persist
Some patients fear that anxiety (and anxiety-related bodily sensations) will persist
indefinitely or spiral “out of control” if rituals are not completed. For example, “If I don’t
re-arrange the closet, I will never get over the feeling that things aren’t just right.”
Questions to help elicit these types of cognitions include:
• Do you worry that you will become anxious and that the anxiety will never go away?
• What might happen to you if you remained anxious for long periods of time?
Because this type of fear is not always readily apparent to the patient, some patients
have difficulty articulating that what they fear is actually the experience of feeling very
anxious (i.e., sensations associated with the fight/flight response). These individuals
might require prompting to be able to describe such concerns (e.g., “Some people with
OCD have the fear that if they don’t ritualize, their anxiety will go on endlessly and spiral
out of control. Do you worry about this?”).
Assessing Responses to Obsessional Distress
Determine the patient’s maladaptive response to obsessional fear
It is essential for the therapist to determine the patient’s maladaptive responses to
obsessional fear (i.e., neutralizing, safety-seeking rituals) because such behaviors
maintain OCD. All safety-seeking behavior (even covert responses) must be targeted in
response prevention.
Passive Avoidance
Most patients avoid situations and objects associated with obsessions in order to
prevent feared disasters. Examples include avoidance of certain people (e.g., cancer
patients), places (e.g., public washrooms), situations (e.g., using pesticides, bathing one’s
infant), and certain words (e.g., “murder”). Pay particular attention to subtle avoidance
habits such as staying away from the most used surface or refraining from listening to
music while driving. Ascertain the cognitive basis for avoidance (e.g., “if I listen to music,
I might not realize it if I hit a pedestrian”). Examples of questions to elicit this
information include:
• What situations do you avoid because of obsessional fear?
• Can you ever confront this situation?
• How does avoiding _____ make you feel more comfortable?
Overt Compulsive Rituals
List all ritualistic behaviors including cleaning, checking, repeating actions, arranging
objects, and asking for reassurance. Attend to inconspicuous behaviors such as wiping,
the use of special soaps, and visually checking. Determine the cognitive basis for rituals
(i.e., the relationship between rituals and feared consequences). For example, checking
to prevent fires and using a certain soap to target certain kinds of germs. Examples of
questions to elicit this information include:
• What do you do when you can’t avoid (insert situation)?
• Tell me about the strategies or rituals you use to reduce obsessional fear of (insert
obsessional fear).
• How does doing this ritual reduce your discomfort?
• What might happen if you didn’t engage in this ritual?
Mental Rituals and Covert Neutralizing Strategies
Inquire about mental rituals and other covert neutralizing strategies
Inquire about the use of mental rituals to neutralize unacceptable obsessional thoughts.
Examples include thinking special “safe” thoughts, phrases, and images; repeating
prayers in a set (or “perfect”) way; mentally reviewing (over and over) one’s actions to
allay obsessional doubts; and habitual thought suppression and mental distraction.
Ascertain the cognitive links between mental rituals and misinterpretations of
particular obsessional thoughts. For example, repeating the phrase “God is good” to
avoid punishment for having sacrilegious thoughts, and suppression of violent thoughts
to prevent acting violently. Examples of questions to elicit this information include:
• What kinds of mental strategies do you use to dismiss unwanted thoughts?
• What might happen if you didn’t use the strategy?
Ask the patient for a “play-by-play” description of OCD symptoms to illustrate a typical
episode
Clinical Pearl
The Play-by-Play Description
To gain additional insight into the patient’s experience and how he or she copes with symptoms, you
can ask for a “play-by-play” description of a few specific instances of obsessional fear, avoidance, and
ritualistic behavior. This technique could also be used to focus the assessment on a particular
symptom you are having difficulty understanding. It involves asking questions such as, “What was
the context in which obsessional distress was evoked?” and “What was the first sign of trouble?”
Patients are asked to step through the situation and report their emotional and cognitive responses.
What were they feeling and thinking? What happened next? How anxious did the patient become
and what did they do to reduce this anxiety (rituals, avoidance)? How did the situation resolve itself
and how did they feel afterwards? You can also point out the relationships between obsessions and
increased distress, and between rituals or avoidance and anxiety reduction. Illustrating to the
patient how these symptoms are related (as opposed to being bizarre or “out of control”) can instill
hope in the therapy program, as well as a sense of trust in your expertise.
4.1.2 Self-Monitoring
Self-monitoring is an important (and often overlooked) component of CBT
To aid the functional assessment, ask the patient to use the Self-Monitoring Form (see
Appendix) to keep a real-time log of triggers that lead to rituals between sessions.
Explain the form’s importance and give instructions for completing it during the initial
treatment session. Some patients fail to carefully and accurately self-monitor because
they do not appreciate the task’s relevance to treatment (many see it as “busy work”).
To increase adherence, convey the following:
• Self-monitoring helps both the therapist and the patient gain an accurate picture of
the time spent engaged in, and situations that lead to, rituals.
• It helps the patient identify obsessions and rituals that he or she might not be aware
of.
• Some patients use the fact that they have to report their rituals to the therapist as
motivation to resist the rituals.
• Accurate reporting of rituals between now and the end of treatment will reveal how
much progress is made in therapy.
With the patient’s input, choose which rituals will be monitored (i.e., the most
prominent ones). Then, give the following instructions:
• Rather than guess, use a watch to determine the exact amount of time spent
ritualizing.
• To avoid forgetting important details, record each ritual immediately, rather than
waiting until the end of the day (or worse, right before the next session).
• Write a brief summary of the situation or thought that evoked the ritual.
A useful way to train patients to self-monitor is to review a recent ritualistic episode (or
an “imaginary day”) with the patient and have him or her practice recording the date
and time, situation or thought that evoked the ritual, and the amount of time spent
ritualizing. To further increase adherence, tell the patient that the first item on the
agenda for the next session will be to review the self-monitoring forms.
4.1.3 Psychoeducation
Psychoeducation helps socialize the patient to the cognitive-behavioral approach to OCD
The educational component of CBT helps the patient learn to conceptualize OCD
symptoms based on the cognitive-behavioral model. It also teaches the patient how
these symptoms are weakened by the techniques used in CBT (e.g., exposure). The main
concepts to be conveyed are: (a) unwanted intrusive thoughts are normal, (b)
dysfunctional interpretations of intrusive thoughts cause obsessions, (c) avoidance and
compulsive rituals maintain obsessions, and (d) there is a coherent rationale for CBT.
This rationale is especially important since patients who do not see how exposure and
response prevention ultimately produce benefit can not be expected to fully engage in
these challenging CBT techniques.
Explaining the functional relationship between obsessions and rituals
Begin by helping the patient to understand OCD symptoms as patterns that can be
broken with practice. Convey the following points:
• The treatment techniques are based on the idea that OCD is a set of patterns of
thinking and behaving that become a vicious cycle and that require help to break.
• Maladaptive thinking patterns in OCD involve overestimating the danger associated
with obsessions, which leads to feeling anxious when certain situations and thoughts
are encountered.
• The anxious feelings lead to urges to do something to reduce the anxiety or to
prevent something bad from happening.
• The maladaptive behavioral patterns include rituals and other strategies that reduce
obsessional anxiety.
• Rituals are counterproductive because they only reduce anxiety temporarily, yet in
doing so, become stronger and stronger habits.
• The OCD thinking and behaving patterns can become so intense over time that they
become disruptive in your life.
The next sections present modules for socializing patients to the cognitive-behavioral
model of OCD and its treatment.
Normalizing Obsessional Thinking
Everyone has obsessional thoughts
Unwanted, senseless, or bizarre intrusive (obsessional) thoughts, ideas, or images are
present to some degree in all presentations of OCD. Sometimes these thoughts are
triggered by external stimuli (e.g., knives, toilets), whereas at other times they may be
unprovoked (unwanted sexual images). Explain to the patient that such thoughts (no
matter how repugnant or upsetting), are normal experiences for over 90% of the
population. People with OCD habitually misinterpret these thoughts as highly
significant, whereas nonpatients correctly disregard them as “mental noise.” It may be
helpful if therapists share examples of their own experiences with intrusive thoughts to
demonstrate the normalcy of these experiences and to model acceptance of such
“strange” occurrences. Most patients are surprised and relieved to find out that just
about everyone has unwanted intrusive thoughts.
If the patient wants to know why people have strange or unwanted thoughts in the first
place, explain that the human brain is highly developed and capable of enormous
creativity. People can imagine all kinds of scenarios—some pleasant, and others
unpleasant. For example, many people daydream of winning the lottery or scoring the
winning touchdown in the Superbowl. Just as our “thought generator” produces positive
thoughts that are unlikely to come true, it can also spawn unpleasant thoughts.
Underscore that the problem in OCD is not that obsessional thoughts occur per se, but
how the person appraises these thoughts as very meaningful or threatening. Thus, the
aim of treatment is not to eliminate obsessional thoughts altogether, but rather to
correct the misappraisals and reduce the amount of distress associated with these
normally occurring experiences. Once intrusive thoughts are no longer perceived as
threatening, it won’t matter when or how frequently they occur. Give the patient the
Everyone has Intrusive Thoughts handout (see Appendix) to be read after the session
is over. The handout reviews this didactic information and includes a list of intrusive
thoughts reported by people without OCD.
Normalizing intrusive thoughts is useful for individuals with any OCD symptom
subtype, although the most straightforward application is for unacceptable aggressive,
blasphemous, and sexual obsessions, and with intrusive doubts. For patients with
contamination symptoms this exercise can be used to normalize images of germs and
doubts about illnesses. Senseless thoughts and ideas concerning the “need” for order,
symmetry, balance, and exactness can also be normalized this way.
Patients may point out that although everyone has intrusive thoughts, their own
intrusions are more frequent, more distressing, and more intense compared to those of
nonsufferers. This is true, and it is therefore important for patients to understand how
their own detrimental thinking patterns (which they can learn to change) are the real
culprit. Dysfunctional beliefs cause normal intrusive thoughts to escalate into highly
distressing and recurrent obsessions.
The Role of Dysfunctional Interpretations in OCD
Dysfunctional beliefs and interpretations give rise to emotional distress
The idea that emotional and behavioral responses are determined by one’s beliefs and
perceptions about situations (not by situations themselves) forms the philosophical
basis of CBT. Patients must understand the process by which their dysfunctional beliefs
and interpretations can lead to emotional responses, such as anxiety. Strong emotions,
in turn, exacerbate obsessional thinking.
According to Beck’s cognitive model, dysfunctional thinking may occur on two levels.
Automatic thoughts are in-situation appraisals that go through a person’s mind and
provoke an emotional or behavioral response. For example, when someone with
obsessions about germs drops a coin on the floor they may think, “I’ll get sick if I touch
the coin and don’t wash my hands.” Dysfunctional assumptions, on the other hand, are
general underlying beliefs that people hold about themselves and the world which make
them inclined to interpret specific situations and stimuli in a catastrophic manner. For
example, the beliefs “I am highly susceptible to illness” and “if I think it, it will happen”
would evoke distress and urges to ritualize if one had to pick up a coin from the floor.
Unlike automatic thoughts, dysfunctional assumptions usually do not enter a person’s
consciousness during the anxiety-evoking situation.
Helping the patient understand the relationship between thoughts and emotions
The vignette that follows illustrates the use of Socratic dialog in which the therapist
helps the patient understand how her thinking dictates her emotional and behavioral
responses. After illustrating this model using a situation that is not emotionally charged,
the next step is to apply it to an OCD-relevant situation. The patient in the example had
an excessive fear that she would catch the herpes virus from a particular coworker who
once had a cold sore on her lip.
Clinical Vignette
Illustration of the Cognitive Model with NonOCD-relevant Situation

Therapist:
Patient:
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Clinical Vignette
Illustration of the Cognitive Model with OCD-relevant Situation

Therapist:
Patient:
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Patient:
Therapist:
As we have seen, the anxiety evoking stimuli in OCD are often intrusive thoughts.
Applying the cognitive model with thoughts as triggers can be tricky since these stimuli,
and the maladaptive beliefs and interpretations, are all mental events. Therefore, you
should help the patient to distinguish between (a) intrusive obsessional thoughts and
(b) automatic thoughts or appraisals of these intrusions as in the following example.
The patient was devoutly religious, yet experienced intrusive sacrilegious thoughts such
as “Jesus wasn’t perfect” and “the Church isn’t perfect.” He interpreted these thoughts as
meaning that despite strong devotion to his faith, he was really a fraud who deserved to
be excommunicated from the church.
Clinical Vignette
Distinguishing Between Intrusive Obsessional Thoughts and Automatic Thoughts
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Patient:

Therapist:

The Role of Avoidance and Safety-Seeking in Maintaining OCD

Explaining how safety-seeking behavior maintains obsessional fear
Patients must understand how their avoidance and safety-seeking behaviors (rituals,
and other forms of neutralization) contribute to the vicious cycle of OCD. This will
provide a rationale for response prevention. Discuss the following points with the
patient.
• Review how obsessions increase anxiety and compulsive rituals temporarily
decrease anxiety.
• Aside from compulsive rituals, there are other strategies that individuals often use
that have the same effect as rituals. These include avoidance and subtle (mini) rituals
(i.e., neutralizing).
• These strategies are collectively termed safety-seeking behaviors because they lead
to feeling safe—like something awful has been avoided.
• Avoidance and rituals might seem strange, bizarre, or “out of control.” Help the
patient view them as anxiety-reduction strategies. Give an example of how rituals are
used to neutralize obsessional anxiety. Make sure the functional relationship between
obsessions and compulsions is understood.
• Rituals would be adaptive responses if there were real danger present. But,
obsessional fear is based on misinterpretations. So, these responses are unnecessary
and counterproductive.
• Avoidance tricks patients into thinking that they have averted catastrophe (give
examples of the patient’s avoidance patterns; e.g., “if you avoid touching the bathroom
door with your hands, and you don’t get sick, you will think that it’s because you didn’t
touch the door”). Avoidance also keeps the patient from learning that the feared
situation isn’t really dangerous.
• When obsessional stimuli can not be avoided, the next best solution is to search for a
way to escape from the feared situation and relieve the anxiety as quickly as possible in
any way that seems to work (provide examples of how the patient’s rituals are used to
escape from obsessional fear). Because the escape strategies also reduce distress, they
develop into patterns (negative reinforcement).
• Neutralizing strategies are another maladaptive response to obsessions that provide
a temporary escape from distress, but that make things worse in the long run (give
examples of the patient’s neutralizing responses). Neutralizing also increases
preoccupation with obsessional thoughts.
• In summary, safety-seeking behaviors are responses to obsessions that seem helpful
in the moment, but that backfire in the long run.
• Treatment will weaken these patterns by creating opportunities for the patient to
learn that safety behaviors are not necessary to reduce anxiety or prevent negative
outcomes.
Integrating psychoeducation into the functional assessment
Clinical Pearl
Integrating Psychoeducation into the Functional Assessment
A useful way to think about the initial sessions of CBT is as an exchange of information between
patient and therapist. On the one hand, the patient is an “expert” on his or her particular OCD
symptoms and must help the therapist understand the nuances of these symptoms in order that an
individual treatment plan can be developed. On the other hand, the therapist is an expert in
conceptualizing OCD symptoms and must teach the patient to understand his or her symptoms in a
way that best fosters benefit from the treatment procedures.
In our clinic, we explain this situation to patients at the very beginning of the functional assessment
phase. We weave the psychoeducational component into this assessment by capitalizing on any
opportunities to help the patient understand the functional aspects of his or her symptoms. For
example, when assessing obsessional thoughts, if a patient describes his or her intrusive thoughts as
“strange” or “abnormal”, or insinuates that he or she is the only person with such thoughts, we begin
educating him or her immediately about the normalcy of unwanted thoughts. This technique helps
socialize the patient to the cognitive-behavioral model of OCD, which is critical for a positive
treatment response.
Presenting the Rationale for CBT
Presenting the rationale for using the specific CBT techniques to reduce OCD
Once the patient has a grasp of the cognitive-behavioral model, present a rationale for
CBT by discussing the following points:
• The treatment techniques, exposure and response prevention, are designed to
weaken the maladaptive thinking and behavior patterns in OCD.
• Exposure involves gradually confronting situations and thoughts that evoke anxiety.
Response prevention involves refraining from doing anything to get rid of obsessional
anxiety, except staying exposed to the situation.
• Give examples of specific exposure and response preventions exercises that might be
prescribed for the patient.
• The basic idea of exposure therapy is simple. Repeatedly confronting situations and
thoughts that evoke anxiety helps the patient learn that anxiety does not remain at high
levels or spiral “out of control.” Instead, distress actually subsides. This is called
habituation. Since the patient usually escapes from the feared situation (by doing
rituals) before anxiety subsides, he or she never has the opportunity to see that
habituation eventually occurs.
• Therapy also helps the patient learn that obsessional fears are unlikely to occur even
if no rituals are performed.
How to explain the concept of habituation
Draw a graph similar to that in Figure 2 to depict the within- and between-sessions
habituation curves over the course of several exposure sessions. Discuss the graph as
follows:
• The patient should expect to feel anxious at times, especially when starting to
confront the feared situation. But this distress is temporary—it will eventually subside
if the patient remains in the feared situation without using safety behaviors.
• The graph shows what happens with repeated and prolonged exposure. At the start
of the first session, discomfort increases and then declines as time passes. At the second
session, the discomfort subsides more quickly because learning has occurred. After
several exposure trials the initial distress level is lower and it subsides even more
quickly because the patient has learned that the situation is not highly dangerous. With
repeated practice, the feared situations no longer provoke anxiety.

Figure 2
Expected pattern of within-session and between-sessions habituation during
repeated exposure
• This pattern only occurs if the exposure exercise is carefully
designed and if the patient remains exposed for a long enough time without performing
rituals (i.e., the patient must “invest anxiety now in order to have a calmer future”).
• There are two kinds of exposure. Situational or in vivo exposure means facing the
actual feared situations. Imaginal exposure means facing fears in imagination.
• Exposure with response prevention is often very helpful for OCD, but it is hard work
and must be done correctly in order to get good results.
The patient should understand that treatment is tailored to his or her specific OCD symptoms
Next, discuss how you will work with the patient to tailor the treatment program to his
or her needs.
• The patient will help the therapist make a list of exposure stimuli that will be put in
order from less anxiety-provoking situations to those that are more difficult.
• Exposure exercises will be planned ahead of time as to avoid surprises.
• The therapist will provide support and coaching during each exposure task.
• Sometimes, treatment instructions might seem especially risky, or involve doing (or
thinking about) things that most people wouldn’t ordinarily do (or think about) on
purpose. The patient must understand that the purpose of exposure and response
prevention is not just to practice doing what most people do. These tasks are designed
to weaken OCD symptoms.
The therapist is essentially the patient’s “coach” for overcoming OCD
The relationship between patient and therapist in CBT is analogous to that between a
student and a teacher, or between a ballplayer and a coach. In the example below, the
therapist explained his role as similar to that of a music teacher.
Clinical Vignette
Describing the Patient/Therapist Relationship

Therapist:

4.1.4 Using Cognitive Therapy Techniques

Using cognitive therapy techniques
Cognitive therapy techniques for OCD teach patients to identify, evaluate, and modify
dysfunctional thinking patterns (i.e., maladaptive beliefs and assumptions) that give rise
to obsessional fear and compulsive urges. Patients are helped to develop realistic beliefs
about anxiety-evoking situations and thoughts.
What is the role of cognitive therapy in CBT for OCD? Research shows that cognitive
techniques by themselves have limited efficacy in reducing OCD symptoms. However,
cognitive therapy can play a role in helping to facilitate assessment, preventing
premature discontinuation, and maximizing adherence with exposure therapy (Kozak &
Coles, 2005). I suggest using cognitive therapy strategies to “set the table” for exposure
and response prevention. That is, to “tenderize” dysfunctional beliefs and assumptions
to the point that the patient can more readily engage in and profit from exposure
exercises. Ways of integrating cognitive therapy with exposure are discussed below.
Discussing and Challenging Cognitive Distortions
Identifying ways in which the patient misinterprets situations and thoughts raises
awareness of how such thinking patterns lead to obsessional fear. Instead of providing
didactic information or reassurance, you should promote collaborative empiricism by
asking relevant questions to help the patient discover for him or herself an
understanding of how maladaptive thinking patterns maintain OCD symptoms. The
Appendix provides a list of cognitive distortions present in OCD. Review this handout
in the session and explore with the patient how these thinking styles might play a role in
his or her particular symptoms. The text below presents modules for challenging some
of these maladaptive thinking patterns.
Intolerance of uncertainty
Avoidance and safety-seeking behavior in OCD represent attempts to guarantee safety.
It is as if patients believe the absence of complete reassurance of safety implies a high
risk of harm (in contrast, nonsufferers assume situations are safe if clear-cut danger
signs are absent). Put another way, people without OCD have the adaptive ability to feel
certain about many things despite the fact that absolute certainty is more or less an
illusion. You can use the following demonstration to illustrate this problem:
Help the patient understand how intolerance of uncertainty contributes to OCD
Clinical Vignette
Clarifying the Function of Avoidance and Safety-Seeking Behavior in OCD
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Patient:
Point out that it is impossible to be 100% certain in this (and in most situations).
Medical emergencies, etc., can occur. Yet, in this experiment, the patient based his
judgment on a probability as opposed to a guarantee of safety. Next, discuss other low
probability “risks” that the patent takes on a regular basis (e.g., driving home from the
session) to demonstrate that the patient knows how to properly manage uncertainty. To
reduce OCD symptoms, however, he or she must be willing to practice living with
uncertainty about obsessional fears as well.
Intolerance of uncertainty underlies obsessional fears of events that might occur in the
distant future (e.g., cancer from long-term exposure to pesticides, going to Hell).
Patients often argue that they “cannot take the chance” of the feared event coming true.
Here, you can point out that they would benefit by developing an alternative, less
threatening, interpretation of the experience of uncertainty. This is illustrated in the
example below of a patient with obsessional fears of becoming schizophrenic:
Clinical Vignette
Managing Fears of Future Events
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Overestimation of threat
Patients with anxiety disorders often overestimate the probability and severity of threats
People with OCD tend to exaggerate the risk of harm associated with obsessional
situations in two ways: by overestimating the (l) probability and (2) severity of the
feared outcome. These thinking patterns fuel anxiety since they imply that danger is
lurking. Cognitive techniques can help the patient develop more realistic ways of
thinking about the potential for harm. An example of a Socratic dialog between a patient
and her therapist is presented below:
Clinical Vignette
Example of a Socratic Dialog Looking at Overestimation of Threat
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Sometimes patients reason that although feared outcomes may be unlikely, they could
occur; so taking precautions such as avoidance and rituals is prudent (“better safe than
sorry”). Such thinking indicates that the patient is still ignoring pertinent evidence to
the contrary. Patients may also believe that avoidance and safety-seeking rituals have
prevented feared outcomes. For example, a patient with unwanted impulses to harm
her baby might say that she did not act on the violent thought because she neutralized
it with a “safe” thought. Such arguments call for revisiting the psychoeducational
module explaining the mechanisms by which compulsive behavior maintains
overestimates of threat.
Overestimation of responsibility
Some patients have an inflated sense of their power to cause or prevent negative
outcomes (e.g., “if I don’t pray that my loved ones are safe, it is as bad as purposely
injuring them”). You can help such individuals gain perspective on their degree of
responsibility for feared outcomes by having them identify all possible contributing
factors and then rating how much each factor contributes (what percent) to the overall
responsibility for such an event. This information can be incorporated in a pie chart to
visually illustrate the logical error as in Figure 3.

Figure 3
Illustration of the pie chart method for a patient with obsessions concerning
responsibility for accidents
The patient in this example had obsessional fears that she would be responsible for her
boyfriend dying in a car accident. She felt she had to ritualistically “bless” him by saying
certain prayers in order to prevent such a catastrophe. The therapist asked the patient
to list factors, other than herself, that might contribute to an accident. The patient cited
bad weather, other drivers, sleepiness, a car malfunction, and road construction. Next,
the percent responsibility attributable to each of these contributions was rated and
drawn in as pieces of the pie. The leftover part of the pie was labeled as the patient’s
own contribution (5%) and she was able to see that by her own rating, her
responsibility for the feared outcome was minimal.
Significance of thoughts (thought-action fusion)
Beliefs that merely thinking blasphemous, aggressive, or sexual thoughts is equivalent
to “immoral” behavior indicate the need for additional discussion regarding the
normalcy (and unimportance) of intrusive upsetting thoughts. Ask the patient what she
or he thinks of the fact that even virtuous, ethical, and kind people sometimes have
similar “bad” thoughts. If a double standard is present, this should be pointed out and
alternative explanations can be discussed.
If the patient believes that unwanted thoughts will lead to the corresponding event,
explore his or her ideas regarding the mechanism by which this could occur (e.g., “How
do you think your thoughts of stabbing your baby will lead you to commit this action?”
“How will thinking about your sister having a car accident make it happen?”).
Inconsistencies with reasoning can then be explored through Socratic questioning to
encourage the patient to re-think such assumptions (e.g., “If thoughts lead to actions,
how are people able to maintain control of themselves when they get angry?” “Can you
recall a time when you thought of something and it didn’t happen?”).
If the patient is concerned that such obsessions imply he or she is a dangerous or
immoral person, the discussion can focus on the “kinds” of people who would and
would not be upset by violent, blasphemous, or sexual thoughts. Unlike the patient,
someone intent on committing violence would not worry if they had thoughts about
such behavior. A pervert would not be upset by sexual impulses. An atheist would not
be concerned over sacrilegious images. Does the patient have a history of behavior or
thoughts consistent with these obsessions? (probably not).
You can use the following experiment to further illustrate this point: Hand the patient a
delicate object and ask him or her to think about throwing the object across the room.
When he or she does not throw the object, discuss the various factors that contribute to
performing actions (e.g., decision-making). Thoughts, by themselves, do not translate to
impulsively engaging in behaviors. This and other similar exercises (e.g., going outside
and “wishing” for car accidents, buying a lottery ticket and thinking of winning)
demonstrate that one need not worry about intrusive senseless thoughts.
Need to control thoughts
The need to control thoughts follows from dysfunctional beliefs about the importance of
thoughts
The need to control thoughts follows from beliefs about the overimportance of thoughts.
However, if patients are unaware of how their attempts at thought control are destined
to fail, they might believe that their mind is “out of control.” One technique for
demonstrating the futility of attempts to control unwanted thoughts is to engage the
patient in the following experiment:
Therapist: Let’s try an experiment. I’d like you to try not to think of a pink elephant for
one minute. You can think of anything else in the world except for a pink elephant. OK?
Go.
How to demonstrate the futility of trying to suppress obsessional thoughts
Invariably, the patient will have pink elephant thoughts and agree that it is nearly
impossible to fully suppress them. Next, ask the patient to explain how this
phenomenon applies to obsessional thoughts. Such a discussion should focus on how
attempts to suppress obsessional thoughts lead to more unwanted distressing thoughts
and even more futile attempts to suppress. Of course, suppression attempts are
unnecessary since obsessional thoughts are not dangerous in the first place.
Perfectionism and the “just right” error
In discussing beliefs about perfection, help the patient recognize that such an “all-or-
nothing” approach is futile since perfection is largely an illusion. Help him or her to
identify instances (unrelated to OCD) in which perfection is not demanded and in which
there is no associated distress. This means the patient knows how to manage
imperfection, yet must learn to apply this where OCD is concerned.
Severe perfectionism can interfere with the completion of therapy assignments (e.g., “If
I can’t do it perfectly, there’s no sense in doing it at all”). In such cases, instruct the
patient to purposely complete such tasks imperfectly to test out whether feared
outcomes (e.g., failure to benefit) really occur.
Capitalizing on opportunities to maximize cognitive change
Clinical Pearl
Capitalizing on Opportunities to Maximize Cognitive Change
The liberal use of cognitive techniques throughout a course of CBT for OCD is encouraged. A few
examples of how these strategies can be applied at various points appear below.
• During exposure exercises (described in Section 4.1.6), help the patient process his or her
experience. Review evidence regarding the probability and severity of feared consequences that is
gleaned by performing the exercise. Help the patient articulate more realistic beliefs about
obsessional stimuli.
• When a patient shows strong affect, ask him or her to identify thoughts and images leading to
their emotional response at that moment. Using Socratic questioning, address dysfunctional beliefs
and assumptions. Apply this to OCD as well as to unrelated issues that may arise (e.g., a romantic
break-up)
• Point out and summarize changes in beliefs during and after the completion of exposure exercises.
Once the patient is socialized to the cognitive-behavioral model, ask him or her to provide such
summaries.
• If self-monitoring forms indicate continued ritualizing, help the patient identify underlying
dysfunctional cognitions. For example, “What were you saying to yourself when you saw the fire
engine and decided to go home to check whether the appliances were unplugged?” and “What were
the short-and long-term consequences of your ritualizing?”
4.1.5 Planning for Exposure and Response Prevention
The aim of exposure and response prevention for OCD is to allow the patient to have
experiences in which obsessional stimuli are confronted without the use of safety-
seeking rituals, but where feared outcomes do not materialize and the only explanation
is that the obsessional stimuli are not as dangerous as was thought. The fear hierarchy
is a list of the situations, stimuli, and thoughts that the patient confronts during
exposure sessions. Hierarchy items must match the patient’s particular obsessional
fears and they are ranked according to the level of distress that the patient expects to
encounter during exposure to that particular item.
Building the Fear Hierarchy: Situational Exposure
Designing the fear hierarchy
Informed by the functional assessment, and with the patient’s assistance, compose a list
of between 10 and 20 situations that evoke the patient’s obsessional fear. Record these
situations in the top portion of the Fear Hierarchy Form (see Appendix). Suggestions
for choosing suitable hierarchy items appear below. Examples of fear hierarchies
appear in Chapter 5.
The guiding principle when deciding on exposure hierarchy items is that these
situations and stimuli must closely match the patient’s particular obsessional fears.
Therefore, patients with contamination fears must confront items such as floors,
elevator call buttons, toilet seats, shoes, door handles, feces, pesticides, hospitals, feared
people (e.g., shaking hands), sweat, etc. Items that serve as reminders of contaminants
(e.g., a book that belonged to a gay person) might also be incorporated if such stimuli
are avoided. Exposure for patients with fears of mistakes or harm (negligence) might
involve leaving the stove on and going outside, locking the door in a “careless” way,
completing assignments hastily without checking for accuracy, driving on crowded
streets, placing sharp objects on the floors in public places (fear of responsibility for
accidents), or thinking curse words before writing important letters (fear of
unknowingly insulting others). Individuals with fears of bad luck might confront
“unlucky” numbers (e.g., 13, 666) or words (e.g., “death”), blasphemous phrases, or the
Satanic Bible. Those with violent obsessions would confront items that trigger violent
thoughts, such as knives. Those with sexual or religious obsessions would confront
whatever stimuli evoke unacceptable ideas, such as pornographic material, religious
icons, and the like. Finally, for patients with concerns about symmetry and order,
exposure would entail confronting the kinds of imperfection, disorder, imbalance, etc.
that the person tries to avoid. Details for how to conduct exposure to these various
stimuli are provided in Section 4.1.6
Choose exposure tasks that represent “ordinary levels of risk” within the confines of
your (or an expert’s) judgment. Situations or stimuli that evoke the patient’s worst
obsessional fears must be included on the hierarchy. Failure to confront the worst fears
reinforces the mistaken idea that such situations should be avoided because they really
are too dangerous.
It is not essential that every possible fear cue appear on the hierarchy. Items should be
detailed enough to advise the patient and therapist of the nature and difficulty of the
exposure exercises, yet leave open the option to modify the specific task(s) in accord
with the patient’s specific fears. This permits flexibility in developing exposures of
varying degrees of difficulty as needed (some of which might not be contrived until the
particular exposure is begun). The vignette below illustrates how to include the patient
in selecting items.
The best exposures are those which allow patients to test (and disconfirm) their fears of
disastrous consequences (e.g., “I will hit people with the car”). However, in some
instances feared consequences pertain to disasters in the distant future and are
therefore not subject to immediate disconfirmation (e.g., going to hell when one dies). In
such cases, exposure tasks should be designed with the understanding that the aim is to
learn to tolerate acceptable levels of risk and uncertainty.
Clinical Vignette
Putting Together a Fear Hierarchy
Therapist:
Patient:
Therapist:
Patient:
Therapist:
The SUDS scale
Once an initial list of items is generated, ask the patient to assign a numerical rating of
subjective units of distress (“SUDS”) for each item (i.e., “How anxious would you feel if
you confronted ____?”). The SUDS scale includes every number from 0 (no distress) to
100 (maximal distress), although it can be introduced using the anchors shown below:
• 0 SUDS = no distress (like you are asleep).
• 25 SUDS = minimal distress.
• 50 SUDS = moderate distress.
• 75 SUDS = high distress.
• 100 SUDS = maximum distress (e.g., being tied to the railroad tracks as the train is
coming around the bend).
Record the patient’s SUDs rating for each item on the hierarchy form. Next, working
with the patient, establish the order in which hierarchy items will be confronted (and
record this on the hierarchy form). Some considerations for designing this treatment
plan are as follows:
• Begin with moderately distressing items (e.g., 40 SUDS) and work gradually up to the
most disturbing items.
• The most distressing items should be confronted during the middle third of
treatment (about the 10th session).
• During the last third of treatment, exposure to the most distressing stimuli is
repeated in different contexts. The patient also takes more of an active role in designing
and implementing these later exposures.
• Items that were inadvertently omitted from the hierarchy can always be added after
discussion with the patient.
• Each item is first confronted under the therapist’s supervision and then practiced
between sessions.
• Items may be omitted when they evoke little or no discomfort on two successive
exposure trials.
Building the Imaginal Exposure Hierarchy
Imaginal exposure provides a systematic way of repeating and prolonging confrontation
with intrusive obsessional thoughts, images, and urges that evoke anxiety. Scenes to be
imagined are chosen from the list of obsessional thoughts and ideas of feared
consequences generated during the functional assessment. Brief descriptions of these
scenes, their SUDS ratings, and the order in which they will be confronted are entered
onto the bottom part of the Fear Hierarchy Form.
Imaginal exposure
There are three types of imaginal exposure. In primary imaginal exposure, the patient
confronts anxiety-evoking intrusive thoughts, images, and urges which may or may not
be evoked by external cues. Items typically include articulations of a distressing,
graphic, vulgar, or sacrilegious obsessional thought, such as explicit stories of sexual or
violent acts, or descriptions of accidents involving loved ones.
Secondary imaginal exposure involves imagined confrontation with the feared
consequences of not performing rituals. For example, imagining being responsible for
the death of a loved one because rituals were not performed correctly. Secondary
imaginal exposures usually correspond to a situational exposure item. For example, a
patient with fears of fires might leave the iron plugged in (situational exposure) and,
after leaving her home, purposely imagine that she has caused a serious fire.
Preliminary imaginal exposure involves visualizing confrontation with situations and
stimuli before actually conducting situational exposure to that item. This sort of
exposure is generally not planned during the hierarchy development phase, but instead
is inserted as needed when conducting situational exposure. For example, if a patient is
reluctant to engage in a situational exposure to sitting on the bathroom floor, you might
suggest that he or she imagine doing this as a precursor to the actual exposure.
The Response Prevention Plan
The response prevention plan
Although the term “response prevention” engenders images of physically restraining
patients from performing rituals, the procedure is fully voluntary. Optimally, the patient
completely abstains from all rituals and neutralizing behaviors beginning with the first
exposure session. However, some patients require a gradual approach to stopping. Key
considerations when planning for response prevention appear below.
• Revisit the educational materials presented in earlier sections and emphasize the
importance of choosing not to ritualize.
• Define the limits of response prevention and do not require that patients take more
than acceptable risks. For example, if “no checking mirrors while driving” is a rule, allow
for an exception when going in reverse (e.g., one brief check).
• Do not violate cultural or hygienic norms. Patients with washing rituals should be
allowed to shower and brush their teeth each day. However, they should “re-expose”
themselves to contaminants following a shower.
• Specify abstinence from “mini rituals” and subtle safety behaviors that might not
initially be recognized (or reported) as OCD symptoms (e.g., reassurance-seeking).
• If relatives or friends are involved in the patient’s rituals, encourage their help with
response prevention.
Enlisting a designated support person for the patient
Clinical Pearl
Enlisting a Designated Support Person
Some patients encounter difficulty conducting exposure and response prevention tasks
independently (between sessions). It may be useful in such cases to designate a “support person”
such as a close friend or relative who agrees to be available for the patient to assist with treatment
(when called upon by the patient). The support person should meet with the therapist to receive
instruction in how to help with treatment. The best support persons are those who are able to be
empathic yet firm. Individuals who are over-involved in the patient’s symptoms, or who are overly
critical or harsh, should be avoided. The support person is to report any adherence problems to the
therapist.
• For patients who are initially unable to cease all rituals, consider a gradual approach
in which instructions to stop rituals parallel progress up the exposure hierarchy (with
the goal being complete abstinence midway through treatment).
• The patient must record violations of response prevention on Self-Monitoring Forms
and report them to you. Violations indicate trouble spots that require additional work.
Ideas for implementing response prevention for common compulsive rituals
Some typical response prevention rules for common presentations of OCD are as
follows:
Decontamination rituals
Patients are not to use water (i.e., no washing) or other cleaning agents (e.g., hand gels,
wet wipes) on their body. Creams, make-up, bath powder, and deodorants are allowed
as long as they are not used to reduce contamination fears. Water may be drunk or used
when brushing teeth, but not to clean the face or hands (shaving should be done with an
electric razor). One daily 10-minute shower is permitted, but ritualistic washing of
specific body parts is not allowed (unless medical conditions necessitate such
cleansing). Following the 10-minute shower, the patient must re-contaminate with
items from earlier exposures.
Checking, counting, arranging, and repeating rituals
The patient is not to engage in any repetitive behavior. For example, only one brief
glance in the rearview mirror when driving, one quick check of the door when leaving
the home, one rapid proof for errors when completing paperwork, etc. Checking and
counting are not allowed for items normally not checked (e.g., appliances) or counted
(e.g., steps). Counting rituals may be foiled by counting incorrectly. Actions repeated
because of the presence of “bad thoughts” (e.g., going through a doorway) must not be
repeated. Arranging items that appear imperfect is not allowed.
Reassurance-seeking rituals
Compulsive reassurance-seeking from family members, “experts” (e.g., priests, doctors),
or from the therapist, is not permitted. You will need to educate individuals from whom
the patient habitually seeks reassurance about the need to refrain from answering
questions during treatment. Suggest that they respond in a supportive way and refer the
patient back to you. For example, “I’m sorry but I can’t answer your question because I
agreed to help you with treatment. What else could I do to help you manage your
discomfort? Maybe you’d like to call your therapist about this?”
Mental Rituals
Patients are to refrain from mental strategies for canceling (neutralizing) or “putting
right” unacceptable thoughts. Prayers, except as dictated by religious authorities, are
prohibited. Permissible prayers are not to be repeated or used to deal with obsessional
fear. Arranging response prevention for mental rituals requires a discussion with the
patient. He or she might already have a method for blocking rituals. If mental rituals can
not be easily stopped, you can suggest that the patient (a) think of an upsetting thought
instead; or (b) perform the mental ritual in error. For example, if the ritual is to
mentally reassure oneself by reviewing events (e.g., to be sure one did not say curse
words in the synagogue), the review should be purposely foiled (e.g., “I probably said a
curse word”).
Agreeing on the Treatment Plan
The patient and therapist must agree on the treatment plan before CBT begins
The patient and therapist must both agree to adhere to the plans for exposure and
response prevention. Review the following points before moving on:
• Beginning with the next session, the patient will practice facing the situations and
thoughts listed on the exposure hierarchy.
• The patient will also practice refraining from rituals as planned. Resisting rituals will
teach the patient more healthy ways to manage obsessional fear.
• Daily self-guided exposure tasks will be assigned for practice between sessions.
These tasks may be practiced alone or with the supervision of a designated support
person.
• The patient should expect to feel anxious when first facing each new situation, but
must agree to follow the program without arguing with the therapist.
• The therapist will not force the patient into exposure tasks, but will encourage him or
her to choose exposure instead of avoidance.
• The patient must prepare to “tough it out” when the going gets rough. Things may be
challenging in the beginning, but they will get easier. The therapist will be like a coach
that provides instruction and support throughout the program.
• The patient is expected to resist all urges to ritualize. He or she must contact the
therapist (or the designated support person) before carrying out any rituals so that
someone can help with resisting the urges.
• If an urge can’t be resisted, the ritual should be recorded on the self-monitoring form.
The patient must also immediately re-expose him or herself to the situation or thought
which evoked the ritual.
• Treatment should not proceed until the patient agrees to this treatment plan.
4.1.6 Implementing Exposure and Response Prevention
Implementing exposure and response prevention
This section describes how to conduct exposure therapy for OCD. The basic format of
each exposure session is outlined in Table 11. During exposure, the patient confronts
the predetermined hierarchy item(s) and remains exposed, without performing any
rituals or neutralizing behaviors, until the level of distress and urges to ritualize
dissipate. The optimal duration of each exposure session is about 90 minutes.
Checking Homework and Reviewing Self-Monitoring Forms
Reinforce the importance of homework by checking the patient’s forms at the start of each
session
Each exposure session should begin with a general check-in and review of homework
assignments. All forms should be inspected and the patient should provide a qualitative
report of his or her work between sessions. Following up on instructions for homework
and self-monitoring reinforces the importance of working hard between sessions. It also
helps you determine whether all instructions have been followed correctly. When the
patient successfully completes (or demonstrates sufficient effort toward completing)
assigned tasks, this should be rewarded with praise. Be sure to ask what the patent
learned from completing the assignment. When assignments are not completed as
instructed, troubleshoot and, if necessary, complete the homework in that day’s session
before moving on.
Components of exposure sessions
Table 11
Components of Exposure Sessions
Procedure
• Checking in
• Checking homework
• Reviewing self-monitoring forms
• Conducting the exposure exercise
• Agreeing on homework practice
• Planning for the next session’s exposure
Goals for early exposure sessions
Clinical Pearl
Goals for Early Exposure Sessions
To strengthen the patient’s trust and participation in exposure therapy, you should appear
knowledgeable, consistent, and confident. Showing an understanding of the patient’s OCD symptoms,
being up front when discussing the treatment procedures, and taking seriously the patient’s input
also helps strengthen the patient’s conviction in the treatment program.
During initial exposure sessions, help the patient develop good “work habits” for performing these
tasks by attending to (and shaping) the patient’s behavior. Most will have never tried this type of
exercise before. Explain why exposure is to be done in ways that evoke distress. Be democratic (as
opposed to autocratic) and show sensitivity to help the patient view you as an advocate, rather than
a taskmaster.
Introducing the Exposure Task
Begin by describing the specifics of the planned exposure task, including how the feared
stimulus will be confronted, for how long, and what kinds of safety-seeking behaviors
(rituals) are not permitted during and after the exercise. To give the patient an idea of
how the exercise is to proceed, review The 10 Commandments for Successful
Exposure handout (see Appendix) before proceeding with the first exposure. A brief
description of the exercise and an initial SUDS rating should be entered on the
Exposure Practice Form (see Appendix), which is used to keep track of progress
during each exercise.
A typical introduction to an exposure task is as follows:
How to introduce the exposure task
Therapist: At the end of our last meeting, we agreed that the exposure task for today
will be for you to practice writing words you’ve been avoiding, such as “disease,” “AIDS,”
and “cancer.” We’ll begin with easier words, but by the end of the session I’d like you to
be writing even the most distressing words like “tumor” and “death.” So, you will
practice writing these words over and over on this pad of paper. I also want you to allow
yourself to think about any disturbing images that may come to mind. You are not to
“cancel out” these unwanted images, or use other strategies to make you feel less
distressed. Just let the thoughts “hang out” in your mind. I know this is going to produce
anxiety for you, but doing this exposure will help teach you that these words and
thoughts are not dangerous; they will not lead to becoming ill. Also, you will see that
your distress subsides if you don’t try to fight the thoughts. It will also help you to gain a
sense of mastery over your fear—and that would be a nice accomplishment. I will be
keeping track of your anxiety level during the exposure by asking you to rate your SUDS
level every five minutes. So, have in mind a number between 1 and 100 to give me. Are
you ready?
From a cognitive angle, exposure corrects dysfunctional beliefs and interpretations of
obsessional stimuli. Therefore, it is helpful to identify the patient’s feared consequences
of doing the exposure without ritualizing (e.g., “I will get cancer and die”). If negative
consequences are not readily articulated, it might be that the patient fears that their
anxiety or discomfort will persist indefinitely. The feared consequence, as well as the
patient’s estimates of probability and severity, is recorded on the Exposure Practice
Form (see Appendix).
Prolonged and repeated exposure also results in habituation of anxiety within and
between sessions. The Exposure Practice Form includes space for keeping track of the
patient’s SUDS levels at regular intervals through each exposure trial.
Conducting Exposure Exercises
How to conduct exposure exercises for common OCD symptoms
This section presents detailed instructions for conducting exposure tasks for common
presentations of OCD.
Contamination Fears
Contamination exposures should begin gradually and progress according to how the
patient is responding. Start by encouraging the patient to touch the feared contaminant.
If necessary, during early exposures, you might model this by touching the stimulus
yourself. The patient must fully confront the feared stimulus—briefly touching it with
fingertips does not “count.” The patient must feel thoroughly contaminated. He or she
must also focus on, rather than distract from, the stimulus. Regularly asking questions
such as “How are you feeling now?” “What are you telling yourself?” and “What’s your
SUDS?” helps maintain this focus.
The vignette on the next page illustrates exposure to a “contaminated” towel from the
patient’s home bathroom.
Amplifying refers to deliberately intensifying an exposure in order to address a
particular aspect of avoidance. For contamination exposures, this usually means
contaminating items or body parts the patient tries to avoid tainting (e.g., purse, wallet,
face, hair, mouth). As an example, the patient above was instructed to put the towel in
her lap and to touch it to her arms, legs, and face. This was repeated every 5 to 10
minutes until it evoked less discomfort. New areas were added at each amplification.
For example, the patient touched the towel to her purse (inside and out), hair, and
jacket.
Clinical Vignette
Example of an Exposure Exercise with Contamination Fears
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Look for subtle avoidance and safety behaviors such as wiping, opening doors with
one’s feet, and other curious maneuvers that most people don’t do. Patients who appear
to “space out” during exposure should be asked whether they are engaging in
distraction or other strategies such as praying and analyzing. These safety behaviors
might be so habitual that they occur without the patient’s awareness. Therefore, they
must be brought to the patient’s attention whenever they are observed.
The importance of matching the exposure situation to the patient’s obsessional fear can
not be overstated. Patients fearful of “spreading” contamination to other people can
practice shaking hands with “innocent” others. Those fearful of “floor germs” can
conduct entire sessions seated on the floor (in a public bathroom, if necessary). For
those concerned with bodily waste and fluids, we supervise direct confrontation with
such substances (or situations in which the substances might be present). Examples
include, putting a drop of urine on the back of the hand and handling dirty towels from
the gym locker room (fear of sweat).
Obsessional Doubts of Harm and Negligence
Exposure for harming, injury, and mistake obsessions can be complex
Carrying out exposure for harming symptoms is more complicated than for
contamination symptoms. This is because harming obsessions and checking rituals are
usually triggered by circumstances in which the patient perceives a risk of being
responsible for causing or (failing to prevent) harm, injury, or damage. So, exposure in
the presence of a therapist is not necessarily a bona fide exposure since the patient can
transfer responsibility for any negative consequences onto the therapist.
To further complicate matters, many situational exposures for harming symptoms
would be compromised if they are prolonged or repeated during the same session. For
example, plugging in the iron or turning on the stove can only be done once during a
single session because repeating these exercises is inherently a check that no fire has
started. Therefore, necessary precautions must be taken to ensure that no de facto
reassurance seeking occurs that would invalidate the exposure. Instead of repeating
such activities, a good solution is to have the patient perform them once, and then
promptly leave the premises (without checking). The exposure can be prolonged using
secondary imaginal exposure to images of the feared consequences.
Some examples of exposure assignments for patients with harming symptoms and
checking rituals are as follows: A patient who fears hitting pedestrians can perform
driving exposures without checking the roadside or mirror. Someone fearful of causing
a fire or a burglary can practice turning off lights and appliances, or closing and locking
doors, without checking. A patient with fears of stabbing others can use knives and pins
around others. Someone with fears of cursing or insulting others can practice writing
and saying curse words.
When the feared act of commission or omission presents a very low risk of harm,
exposure can involve deliberately carrying out such behaviors. A few examples are as
follows: a patient who fears that failing to warn others of glass on the floor will result in
someone being injured can purposely place pieces of glass on the floor of a crowded
area (and refrain from warning people). Someone fearful of starting a fire can
intentionally leave appliances (even the stove) on and unattended for an acceptable
period of time. A patient who fears miswriting an address on an envelope can purposely
misspell the addressee’s name, street, or city. A person who fears performing
imperfectly could purposefully commit minor “imperfections” as exposure tasks.
Someone afraid of numbers such as 13 or 666 can deliberately write these numbers on
their hand or on pictures of people they would not want to “curse.”
Secondary imaginal exposure should be integrated with situational exposure when
patients report feared consequences of not ritualizing. For example, a patient with
obsessional fears of leaving confidential information out on his desk at work first
completed a situational exposure involving handling confidential files, putting them
away, and leaving the room without double checking. Next, as a secondary imaginal
exposure, he confronted obsessional thoughts of mistakenly leaving the files in the
wrong place and being fired because others had viewed them. The imaginal exposure
was introduced as follows:
Clinical Vignette
Introducing an Imaginal Exposure

Therapist:

The patient then wrote a description of his feared consequences of leaving confidential
materials on his desk and failing to double check. The description was edited with the
therapist to ensure that it contained elements that the patient experienced as most
distressing, such as his irresponsibility for the breach of confidentiality, and the idea
that he should have checked more carefully. The script was then recorded onto a 2-
minute audio loop tape. The patient listened to the tape and visualized the scenes until
his subjective distress declined.
Unacceptable Obsessional Thoughts
Using primary imaginal exposure for repugnant obsessional thoughts
Exposure for unacceptable thoughts involves primary imaginal exposure to the
obsessional thought, image, or impulse; and situational exposure to stimuli that provoke
such obsessions. The patient remains exposed to the obsession, without neutralizing or
performing rituals, until anxiety declines naturally (habituation). The example below
illustrates how to conduct an exposure session for a patient with repugnant stabbing
obsessions.
Clinical Vignette
Introducing an Exposure Exercise for Unacceptable Obsessional Thoughts

Therapist:

The patient was first asked to write a script of her obsessional thoughts. After editing
with the therapist (to highlight the most distressing aspects of the thoughts), the final
version, which the patient recorded onto the loop tape, was as follows:
Sharp objects can be dangerous. I could use them to stab people, which would badly hurt
or kill them. When I use knives, I often think of stabbing innocent people and people that I
especially care about, like my husband, Greg. If people are not expecting to be stabbed, I
could do terrible damage with just a few thrusts of a knife in the right place, such as their
neck, eyes, chest, stomach, or genitals. If a person is not ready, they would not be able to
fight back until it was too late and they would die of their stab wounds that I inflicted.
I could stab Greg while he was sleeping. He would be unaware that I was doing it until the
knife pierced his skin and entered his body. He might wake up in terror and try to fight off
my stabbing, but he would lose so much blood that he wouldn’t be able to fight me off. I
could easily kill him by stabbing him in his sleep. There would be blood everywhere and he
would be screaming from all of the pain. If I stabbed him in the right place, I’d damage his
vital organs and he would die.
The patient listened to the loop tape for 15 minutes and her SUDS decreased from 85 to
65. At that point, the therapist gave the patient a large butcher knife and asked her to
hold it while listening to the tape. After an initial increase in SUDS to 70, her anxiety
declined to 40 after another 20 minutes. At that point, the therapist introduced the
patient to a coworker (who had volunteered to help with treatment). The loop tape was
turned off and patient was instructed to hold the knife while talking with this
confederate. Then, the confederate sat at a computer terminal while the patient held the
knife to the confederate’s back and elicited stabbing thoughts. Finally, this exercise was
continued with the therapist out of the room, but checking in every 5 minutes to obtain
a SUDS rating. When the patient’s SUDS had declined to 25 (after 75 total minutes), the
exposure was ended.
Incompleteness Symptoms
Patients with incompleteness symptoms may or may not articulate fears of harm. When
the sense of inexactness, imperfection, or asymmetry evoke obsessional fears of
responsibility for disasters (e.g., “Dad will die if I do not put on my clothes the ‘correct’
way”), exposure to external cues should be conducted, accompanied by secondary
imaginal exposure to the feared consequences (as would be done in the case of harming
obsessions). Patients must of course be reminded to refrain from rituals such as
ordering and arranging, checking and repeating, and reassurance-seeking. One patient
who worried that stepping on sidewalk cracks would cause harm to his parents
purposely stepped on cracks and confronted thoughts of his parents being injured
because of this. Another feared bad luck from odd numbers and therefore practiced
facing them wherever possible by purchasing items that cost $7.99, and choosing to be
9th in line. He also practiced wishing for bad luck to occur as a result of his
confrontation with odd numbers.
Integrating cognitive techniques into exposure therapy
Clinical Pearl
Integrating Cognitive Therapy with Exposure
Prolonged and repeated exposure exercises help the patient develop more realistic estimates of the
probability and severity of feared consequences. In addition, the decline in distress that accompanies
therapeutic exposure helps to modify dysfunctional beliefs that anxiety will persist indefinitely.
Cognitive therapy techniques should be used at various points during exposure sessions to facilitate
these cognitive changes.
• When initiating an exposure task, cognitive techniques can be used to identify mistaken
cognitions (e.g., “thinking about harm is the same as causing harm”) and feared consequences (e.g., “I
will be responsible for a terrible accident”) that can be tested during exposure.
• During exposures, cognitive techniques can be used to promote adaptive beliefs and responses
to obsessional fear (e.g., “Even if something happens, it’s not my fault”).
• After an exposure exercise, Socratic discussion is used to help the patient review the outcome of
the exercise, examine evidence for and against the catastrophic beliefs, and develop more realistic
beliefs about obsessional stimuli.
When the patient is mostly concerned that anxiety/distress will persist unless items
(e.g., books, clothing) are arranged or ordered properly, exposure aims to desensitize
the patient to the sense of incompleteness. With prolonged and repeated exposure to
the “imperfection,” the patient learns that the distress associated with these feelings
fades over time, thereby rendering ordering rituals unnecessary.
Prescribing Homework Practice
Conclude each treatment session by reviewing progress and discussing plans for the next
session’s exposure exercise
At the completion of each in-session exposure, assign self-controlled (homework)
practices for each day between sessions. Homework includes exposure, refraining from
safety-seeking rituals, and continual self-monitoring of violations of response
prevention. Consider the following points when designing homework assignments:
• Assign repetitions or variations of the in-session situational and imaginal exposure
exercises.
• Provide copies of the Exposure Practice Form to be completed during each
homework assignment. Specify the details of each assignment on the form.
• Suggest that the patient review The 10 Commandments of Exposure handout
before beginning each exercise.
• Reinforce the importance of homework by beginning each session with a check of the
previously assigned work.
Planning for the Next Session
Helping patients confront the most distressing exposure stimuli
At the end of each session the therapist should review the patient’s progress up the
exposure hierarchy and discuss the task scheduled for the next session. If items need to
be brought from the patient’s home, or if the session must take place out of the office,
this should be arranged. Such planning demonstrates your commitment to the therapy
and reassures the patient that there will be no surprises. In short, it engenders trust and
allegiance to the therapist and the therapy.
Conducting Exposure to the Most Distressing Stimuli
Exposure to the most feared hierarchy items should be conducted during the middle
third of the treatment program. This ensures ample therapy time to sort out unforeseen
obstacles that arise while progressing up the hierarchy, or that surface when attempting
to confront the most difficult stimuli. Deciding on a clear timetable for when these
exposures will take place also helps the patient understand the importance of carrying
out these tasks on schedule. Consider that procrastination on the patient’s part might be
a form of avoidance.
Clinical Pearl
Helping Patients Confront their Greatest Fears
For many patients, success with early exercises predicts success with high-level exposures. However,
if the going gets tough, convey sensitivity and understanding that such tasks are highly distressing;
yet also reiterate that this temporary distress is a necessary part of therapy. You can use the
following tactics to help patients who are having difficulty attempting the most difficult exposures:
• Model the task prior to instructing the patient to engage.
• Use intermediate exposures that are of greater difficulty than those already conducted, but not as
difficult as the planned task (the patient must agree that the intermediate step serves to facilitate
eventual exposure with the more difficult item).
• Use cognitive therapy techniques to identify and modify dysfunctional beliefs that are evoking
high anxiety.
• Review evidence collected during previous exposures.
• Discuss the importance of learning to take acceptable risks.
• Revisit the importance of learning to tolerate uncertainty
Planning the most difficult exposures for the middle third of the program also affords
ample time for repeating these exercises in varied contexts. Fear reduction is most
complete and durable when feared stimuli are confronted in a variety of circumstances,
as opposed to only in the therapist’s office. Thus, after the most distressing hierarchy
items have been confronted under controlled conditions, the remaining sessions should
involve repetition of these exposures in varied contexts.
Programmed and Lifestyle Exposure: Encouraging Independence
Programmed and lifestyle exposure
The previous examples primarily illustrate programmed exposure in which the patient
implements planned exercises under your direction at specific times and in particular
locations. Yet patients must also engage in lifestyle exposure, which means making
choices to take advantage of day-to-day opportunities to practice confronting (rather
than avoiding) obsessional stimuli and choosing to be anxious. Encourage the patent
to be opportunistic and to view spontaneously arising obsessional triggers as occasions
to practice treatment techniques and work on further reducing OCD symptoms.
You should routinely remind patients that every choice they make regarding whether to
confront or avoid an obsessional cue carries weight. Each time they choose to confront
such a situation without using rituals, OCD symptoms are weakened. Yet, whenever a
decision is made to avoid a potential lifestyle exposure situation, OCD symptoms are
strengthened.
As it becomes clear that the patient has learned to correctly implement exposure
independently, step back and encourage the patient to become his or her “own
therapist.” This means allowing the patient to design his or her own exposure tasks (e.g.,
by choosing from equally fear-evoking stimuli). Of course, the therapist has the last
word regarding the nature of each exercise, and you must therefore monitor the
planning and implementation of these tasks. This will also prepare the patient for life
after therapy.
Stylistic Considerations
Remarks During Exposure Tasks
What to say (and what not to say) during exposure sessions
Offering appropriate observations, praise, encouragement, and support during exposure
maintains the sort of rapport that is necessary for a successful outcome. Ask the patient
to tell you what he or she is learning by doing exposures. When exercises are
proceeding as planned (i.e., SUDS levels and urges to ritualize are decreasing), the
following sorts of comments and open-ended questions are helpful:
• “You’re doing great. Remember, if you remain exposed to a situation, your anxiety
level decreases on its own.”
• “It looks like you’re much less anxious now compared to when we started the session;
and you haven’t done any rituals. How do you explain that your anxiety is lower?”
• “This seems like it’s getting easier for you. You’re weakening the link between
obsessional thoughts and anxiety. Good for you.”
• “You see, as I told you before, you don’t need to engage in rituals to reduce your
anxiety.”
If the patient is having difficulty with anxiety during the exercise, convey understanding
of how difficult exposure can be, and that with time and persistence, the exercises will
ultimately become more manageable. Offer the following remarks:
• “Sometimes it takes a while for anxiety to go down. That means that you have to stick
with the exposure even though it may be difficult. Eventually, you will begin to feel less
distressed; You’ll be glad you stuck with it.”
• “This time your anxiety did not decrease by much, but we will keep working at it until
it gets easier.”
Avoid providing reassurance that exposure tasks are “not dangerous” or that the patient
is “guaranteed” to be safe. These are things that the patient must learn for him- or
herself. The example below illustrates a helpful and unhelpful way to address patient
requests for reassurance during exposure.
Patient: Are you sure this is safe to do? Normal people wouldn’t do a thing like this!
Unhelpful therapist response: Yes, it’s OK. I promise. I wouldn’t let anything bad happen
to you. Just trust me.
Helpful therapist response: If you are asking me to guarantee you that the situation is
absolutely safe, I can’t do that. I don’t know for certain what the outcome will be. But, I
do know that all the evidence suggests that the risk is low enough that it’s worth trying;
especially if doing this exercise will help with your OCD…
Dealing with strong urges to ritualize
As individuals begin response prevention, they may have difficulty with strong urges to
ritualize. Reviewing how such urges are learned responses to obsessional cues, and how
they diminish over time even if resisted, is useful in helping the patient to resist
violating response prevention instructions. The use of imagery, as in the example below,
can also be helpful. This patient struggled with resisting compulsive urges to check door
locks in her home.
Clinical Vignette
Using Imagery to Manage Compulsive Urges
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Humor
The use of humor or laughter to lighten the mood during exposures may be appropriate
and can be beneficial, although it is not advised in times of extreme distress. Follow the
patient’s lead and ensure that remarks remain relevant to the exposure situation and do
not distract the patient from the task.
Refining the Exposure Hierarchy
Sometimes, important details of the patient’s obsessional fears do not become apparent
until after the exposure hierarchy has been developed. Therefore, as treatment
progresses, the therapist should remain alert for perviously unidentified situations and
stimuli that trigger obsessions, avoidance, or that evoke compulsive rituals. Such
situations should be incorporated into the exposure hierarchy.
Exposure “Field Trips”
The highly specific obsessions and avoidance behaviors of individuals with OCD often
require that exposure exercises be conducted outside of the therapist’s office. Such
“field trips” might include visiting funeral homes, cemeteries, restaurants, places of
worship, hospitals, stores, the patient’s own home, etc. Ideally, the therapist has the
flexibility to leave the office or meet the patient at the site where such exposures can
take place. If not, perhaps a well-coached support person can accompany the patient of
such trips. A final option is for the patient to check in with the therapist by cellular
telephone while conducting the exposure tasks on his or her own.
Usually, exposures in public places can be conducted anonymously. The therapist and
patient should plan in advance how the exercise will proceed so that directives can be
kept to a minimum in public. Necessary behaviors such as touching or rearranging items
should be performed discreetly so as not to draw undue attention. Unforeseen
difficulties, such as high levels of anxiety or a persistent sales clerk, can be managed by
leaving the scene, regrouping, and returning another time. In some situations it may be
ideal to call ahead before visiting exposure situations. For example, calling ahead to let a
funeral home manager know you will be dropping by. In this example, the patient
explained that the purpose of this visit was to help her overcome her fears of funerals.
When a cover story and plans for various contingencies (e.g., running into a friend) are
discussed ahead of time, we find that most patients are willing to go out in public to
conduct exposure with their therapist.
4.1.7 Ending Treatment
This section discusses a number of issues that should be addressed toward the end of
therapy.
Concluding Response Prevention
Helping the patient end response prevention and return to “normal” behavior
As the last session nears, begin to discuss appropriate checking, cleaning, arranging, or
praying behavior. As a rule, if such behaviors are performed in response to fears of
negative consequences, they are probably rituals. Some examples of guidelines for
resuming “normal” behavior after treatment appear below.
• Limit showering to one 10-minute shower per day. A second shower is permitted if
there is extreme perspiration and body odor, or before getting dressed to go out (e.g., to
a formal event). During any shower, wash each body part only once.
• Once the door is closed, you are allowed to turn the handle once to make sure it is
firmly locked. Otherwise, no returning to check is allowed.
Assessing Treatment Outcome
Obtain posttreatment ratings of symptom severity to accurately document progress in
treatment
In addition to informally assessing progress, evaluation of treatment outcome should
include re-administration of symptom measures (e.g., Y-BOCS). Most patients will
report some residual symptoms. Emphasize that “normal” obsessions and rituals are a
part of everyday life for most people, so such experiences will never completely be
absent. However, treatment has helped the patient learn to respond to obsessional
stimuli in new healthy ways. Distress and functional impairment can be minimized with
continued practice of the skills learned in treatment.
Continuing Care
Some patients desire additional treatment. As a general rule, those who have made little
progress after 16 to 20 sessions of well-conducted CBT are unlikely to benefit further by
adding additional sessions. Such individuals might be referred for supportive
psychotherapy to help manage existing OCD symptoms. Attending a support group run
by a local affiliate of the Obsessive Compulsive Foundation (www.ocfoundation.org), if
available, is another good option. If residual OCD symptoms are minimal, yet there is
concern about possible relapse, follow-up sessions can be considered (relapse
prevention programs for OCD are described elsewhere (e.g., Hiss, Foa, & Kozak, 1994).
Alternatively, a less formal strategy involving telephone calls and less frequent (perhaps
monthly) appointments could be undertaken.
Preparing for Stressors
Patients should expect to experience residual OCD symptoms from time to time. Often,
these are triggered by increased life stress, such as in the midst of occupational or
family conflict, following a death or serious illness in the family, or around the time of
childbirth. Help the patient identify potential “high risk” periods during which they
should be ready to apply the techniques learned in therapy.
4.2 Mechanisms of Action
There are three mechanisms by which CBT may reduce OCD symptoms
From a behavioral perspective, CBT is thought to be effective because it provides an
opportunity for the extinction of conditioned fear responses. Specifically, therapeutic
(repeated and prolonged) exposure to feared stimuli produces habituation—the
inevitable natural decrease in conditioned fear. Response prevention aids this process
by blocking the performance of anxiety-reducing rituals, which would serve as a
premature escape from anxiety. Extinction of conditioned anxiety occurs when the
once-feared obsessional stimulus is repeatedly paired with the nonoccurrence of feared
consequences and the eventual reduction of anxiety. From a cognitive perspective, CBT
is effective because it corrects dysfunctional beliefs that underlie OCD symptoms (e.g.,
overestimates of threat) by presenting the patient with information that disconfirms
these beliefs. Cognitive and psychoeducational interventions aim to modify such
cognitions via a verbal-linguistic route, whereas exposure and response prevention
accomplish the same goal experientially. CBT also helps patients gain self-efficacy by
helping them to master their fears without having to rely on avoidance or safety
behaviors.
Foa and Kozak (1986) have drawn attention to three indicators of change during
exposure-based treatment of fear. First, physiological arousal and subjective fear must
be evoked during exposure. Second, the fear responses gradually diminish during the
exposure session (within-session habituation). Third, the initial fear response at the
beginning of each exposure session declines across sessions (between-sessions
habituation).
4.3 Efficacy and Prognosis
There is excellent scientific evidence of the effectiveness of CBT for OCD
Numerous uncontrolled and controlled studies evaluating the effectiveness of exposure-
based CBT for OCD consistently show that patients who complete this treatment achieve
clinically significant and durable improvement (Abramowitz, 1998). Average
improvement rates are typically from 50% to 70% in these studies. A review of 12 trials
(N = 330) indicated that 83% of patents were “responders” at posttreatment. In 16
studies reporting long-term outcome (N = 376; mean follow-up interval of 29 months),
76% were “responders” (Foa & Kozak, 1996). Meta-analytic studies (e.g., Abramowitz,
1996, 1997; Abramowitz, Franklin, & Foa, 2002) show that CBT produces consistently
large effect sizes on measures of OCD, anxiety, and depression.
Recent randomized controlled studies have found exposure-based CBT superior to
waiting list, progressive muscle relaxation, anxiety management training, pill placebo,
and pharmacotherapy by clomipramine (e.g., Foa et al., 2005). These trials indicate that
the effects of CBT are due to the specific cognitive and behavioral techniques (i.e.,
exposure and response prevention) over and above any effects of nonspecific factors
common to all interventions, such as the therapeutic relationship. Moreover, the effects
of CBT are not limited to highly selected research samples or to treatment as delivered
in specialty clinics. Effectiveness studies conducted with nonresearch patients (e.g.,
Franklin, Abramowitz, Foa, Kozak, & Levitt, 2000) show that over 80% of patients who
complete CBT achieve clinically significant improvement. Table 12 shows the results
from studies of CBT in which the Y-BOCS was used as the primary outcome measure.
While CBT is effective for most people with OCD, about 20% do not respond and about
25–30% drop out of therapy. Factors associated with poor outcome (e.g., severe
depression) are discussed in Section 3.4.
Table 12
Effects of Exposure-Based CBT in Trials Using the Y-BOCS

Study
Fals-Stewart et al. (1993)1
Pretest
Posttest
% reduction
Freeston et al. (1997)
Pretest
Posttest
% reduction
Lindsay et al. (1997)
Pretest
Posttest
% reduction
Franklin et al. (2000)
Pretest
Posttest
% reduction
Warren & Thomas (2001)
Pretest
Posttest
% reduction
Foa et al. (2005)
Pretest
Posttest
% reduction
Y-BOCS = Yale-Brown Obsessive Compulsive Scale.
1
Standard deviation not reported in the study.
4.4 Variations and Combinations of Methods
4.4.1 Variants of CBT Treatment Procedures
There is a relationship between treatment outcome and how CBT is delivered along
three parameters. First, better short- and long-term outcome is achieved when
treatment involves in-session exposure practice that is supervised by a therapist, as
compared to when all exposure is performed by the patient as homework assignments.
In fact, the number of hours of therapist-directed exposure is positively correlated with
outcome. Second, combining situational and imaginal exposure is superior to situational
exposure alone. Third, programs in which patients completely refrain from rituals
during the treatment period (i.e., complete response prevention) produce superior
immediate and long-term effects compared to those that involve only partial response
prevention.
4.4.2 Combining Medication and CBT
Research suggests that medication neither adds to, nor detracts from, the effectiveness of CBT
for OCD
The concurrent use of CBT and SRI medication for OCD is common in clinical settings.
The available research indicates that whereas adding CBT to SRIs yields superior
outcome compared to SRIs alone, adding SRIs neither improves nor attenuates the
efficacy of CBT (e.g., Foa et al., 2005). Thus, CBT is an excellent augmentation strategy
for individuals with OCD who remain symptomatic despite adequate trials of SRI
medications.
4.5 Problems in Carrying out the Treatment
Table 13 lists common problems that arise during CBT for OCD. Suggestions for
managing such obstacles are provided below.
4.5.1 Negative Reactions to the CBT Model
Some patients hold the belief that OCD symptoms are caused by a “chemical imbalance”
and therefore “talk therapy” won’t be helpful. Because such a view can lead to
premature drop out, the therapist should openly discuss any doubts the patient has
about the CBT model. Highlight that this model was developed to explain the symptoms
of OCD, not necessarily its causes (therefore, the CBT approach is not incompatible with
a biological approach). You might also point out that studies show CBT has effects on
brain functioning.
Common obstacles to the successful treatment of OCD
Table 13
Common Obstacles in Cognitive-Behavior Therapy for OCD
• Negative reactions to the CBT model
• Nonadherence
– Noncompliance with exposure instructions
– Noncompliance with response prevention instructions
– Continued use of avoidance and subtle rituals
• Arguments
• Therapist’s inclination to challenge the obsession
• Cognitive therapy techniques that become rituals
• Unbearable anxiety levels during exposure
• Absence of anxiety during exposure
• Therapist discomfort with conducting exposure exercises
4.5.2 Nonadherence
The degree of improvement obtained in CBT is often directly related to how well the patient
adheres to the treatment instructions
The most common obstacle encountered in CBT for OCD is the patient’s failure to follow
through with treatment instructions. Many adherence problems can be circumvented by
clarifying how exposure and response prevention reduce OCD symptoms. You should
also actively involve the patient in the treatment planning process.
Noncompliance with Exposure
If a patient refuses to complete exposure tasks (e.g., homework assignments), inquire as
to why this is. Sometimes the problem can be addressed with simple problem solving
(e.g., time management). Also, make sure the exposure task itself is a good match to the
patient’s obsessional fears. If not, the patient might perceive the exercise as irrelevant. If
high levels of anxiety prompt refusal or “shortcuts” (e.g., subtle avoidance, rituals)
during exposure, review the treatment rationale and use cognitive strategies to identify
and address dysfunctional cognitions that underlie reluctance to confront the feared
stimulus.
Refining the exposure hierarchy and adding intermediate items might be appropriate if
the patient threatens to discontinue treatment. However, postponing exposures can
reinforce avoidance. Thus, use this tactic only as a last resort. Instead, use Socratic
questioning to create and amplify the discrepancy between nonadherence and the
patient’s goals. When nonadherence is perceived as conflicting with important personal
goals (such as self-image, happiness, success), it increases motivation for change.
Noncompliance with Response Prevention
If the patient is deliberately concealing ritualistic behavior which was specifically
prohibited by the treatment plan, explain the implications of this problem for treatment
outcome in the following way:
Therapist: Your wife called to tell me that you changed your clothes several times last
weekend after going in the basement. She felt I needed to be aware of this because she
was concerned that you weren’t following the instructions we all agreed to at the
beginning of therapy. We all agreed that if problems come up, you were going to get
help from your wife instead of doing rituals. What happened?
If the patient makes a renewed agreement to adhere to the treatment instructions, the
issue can be dropped. However, if repeated infractions occur, remind the patient of the
rationale for response prevention and raise the possibility of suspending treatment. For
example:
Therapist: It seems that right now you aren’t able to stop your rituals as we had agreed
at the beginning of treatment. Remember that each time you do a ritual you are
preventing yourself from learning that your distress would have declined on its own—
even without the ritual. If you cannot follow the treatment rules, we should talk about
whether now is the right time for you to be doing this kind of treatment.
Continued Use of Avoidance and Subtle Rituals
Perhaps unintentionally, patients sometimes adopt covert tactics for avoiding or
neutralizing obsessional distress once they are told to stop their overt rituals. Examples
include the use of brief actions (e.g., quickly wiping hands instead of washing) or mental
rituals (e.g., instead of asking for reassurance). Although the patient might not realize
that he or she is doing anything wrong, such safety behaviors are functionally
equivalent to rituals: they interfere with habituation and prevent cognitive change.
Therefore, these behaviors must be dropped. If the patient reports that anxiety is not
declining with repeated exposures, inquire about such “mini rituals.” For example, “Now
that you’ve stopped your compulsive rituals, are you doing any little things to relieve
anxiety?”
4.5.3 Arguments
It is important to avoid arguing with patients about the treatment instructions
Some patients become argumentative about the “strictness” of response prevention
rules or the “dangerousness” of exposure tasks. You should resist the urge to lecture the
patient, and instead use Socratic methods so that the belief-altering information is
generated by the patient him or herself.
In the example below, the patient argues that speaking one more time with an
infectious disease expert (Dr. B) would terminate his need for reassurance about the
risk of catching AIDS from public restrooms:
Clinical Vignette
The Use of Socratic Dialog to Address Patient Arguments
Patient:
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Patient:
If discussions about the risks associated with exposure tasks become combative,
summarize the discussion and agree with the patient that his or her assertion could be
correct; but that rather than taking anything for granted, it is better to closely examine
the facts (e.g., using exposure). Do your best to refrain from debates over probability or
the degree of risk. Such arguments reinforce the patient’s OCD habits of spending too
much time thinking about these issues and they amount to little more than a playing out
of the patient’s fruitless (ritualistic) attempts to gain reassurance. Moreover, when
patients perceive that the therapist is frustrated, angry, or coercive (e.g., “you can’t
make me do this”), they lose motivation. Instead, step back and recognize that the
decision to engage in treatment is a difficult one.
What to do if the patient is argumentative
Clinical Pearl
When the Patient Argues
When a patient becomes argumentative (e.g., during exposure), it might indicate a rising level of
distress. Instead of engaging in arguments about risk or “what is normal,” the best strategy is to use
conflict resolution strategies, such as the “broken record technique” (refrain from escalating the
argument by re-stating your original point) or “turning the tables” (identify the problem and ask the
patient what he or she would do to resolve it). Of course, set your limits and know how far it is
reasonable to bend the therapy instructions. Statements such as the following might also be helpful:
• You are here in treatment for yourself—not for me. So, I won’t argue or debate with you. Doing
the treatment is entirely your choice. You stand to get better by trying these exercises and enduring
the short-term anxiety. But you are also the one who has to live with the OCD symptoms if you
choose not to do the therapy.
• Remember that we both agreed on the treatment plan. I expect you to hold up your end of the
bargain.
• I agree with you that there is some risk involved; but it is not high risk. The goal of treatment is to
weaken your anxiety about situations where it is impossible to have a complete guarantee of safety.
• I realize most people wouldn’t go out of their way to do what I am asking you to do. But the
therapy isn’t about what people usually do. These tasks are designed to help you learn to manage
acceptable levels of risk and uncertainty.
• I know this is a difficult decision for you. Yet, if you are going to get over OCD, you have to
confront your uncertainty and find out that the risk is low.
4.5.4 Therapist’s Inclination to Challenge the Obsession
Therapists occasionally fall into the trap of challenging the logic of patients’ obsessional
thoughts per se (e.g., “the impulse to attack an elderly person”) rather than challenging
the patient’s faulty beliefs about the obsessions. The vignette below highlights the
distinction between these two approaches:
Clinical Vignette
Challenging Obsessions
Example 1:
Therapist:
Patient:
Therapist:

Example 2:
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Patient:
Intuitively, the obsession itself seems like a good target for cognitive techniques
because it is a cognitive event and it is irrational. Yet, most patients already recognize
the irrationality of their obsessions. So, direct challenges will have only a transient
therapeutic effect. Moreover, such challenges could turn into reassurance-seeking
strategies used to neutralize the obsession. In contrast, challenging the appraisal of the
obsession gives the patient new information that is different from reassurance.
4.5.5 When Cognitive Interventions Become Rituals
Some patients convert discussions about mistaken beliefs into reassurance seeking
rituals. For example, one patient ritualistically repeated (3 times perfectly) the phrase
“obsessional thoughts are normal” to reduce anxiety associated with his unwanted
homosexual images. Others become preoccupied with identifying the perfect rational
belief that best reassures them that feared consequences are impossible. The best way
to sidestep these problems is to avoid giving the patient a guarantee of safety.
As a general rule, if the patient uses psychoeducational information in a stereotypic
way, or requires increasing clarification to reduce distress, the material is probably
being used as a ritual. In contrast, healthy use of cognitive techniques allows the patient
to generate (him- or herself) new interpretations of obsessional stimuli that lead to
acting appropriately during exposure.
4.5.6 Unbearable Anxiety Levels During Exposure
If the patient becomes extremely anxious or emotional during an exposure, the task
might be too difficult. In such cases, the exercise should be stopped and you should
assess the underlying cognitions. What was it that was so anxiety-provoking? A less
difficult task can be used instead. If the patient is concerned that therapy isn’t working
because anxiety doesn’t subside, emphasize that treatment requires continued practice.
Point out that the patient took an important step simply by choosing to enter the feared
situation in the first place.
4.5.7 Absence of Anxiety During Exposure
If the patient reports little or no distress during exposure, it could mean one of three
things. First, the situation might no longer evoke anxiety. That is, the patient’s
expectations about danger have been modified. This is most likely to occur toward the
end of treatment. In such cases, you can skip to another hierarchy item. A second
explanation is that you have not incorporated the main anxiety-evoking aspect(s) of the
feared situation into the exposure task. To troubleshoot, ask the patient why the
exercise does not evoke anxiety, or how it could be made more anxiety evoking. A third
possibility is that the patient has nullified the exposure with cognitive avoidance or
safety-seeking behavior. For example, before conducting a driving exposure, one patient
called her neighbors to “warn” them to closely watch their children during the time she
would be driving through the neighborhood streets. This absolved her of the
responsibility for harm and therefore she did not become anxious during the driving
exposure. The use of such strategies indicates a problem in understanding the
treatment rationale and must be addressed.
4.5.8 Therapist Discomfort with Conducting Exposure Exercises
If you are not accustomed to using exposure techniques, you might feel apprehensive
about asking patients with OCD to purposely confront stimuli that will evoke
discomfort. Recall, however, that the beneficial effects of CBT are well-documented.
Reducing OCD in the long-run requires evocation of temporary anxiety. Also, recall that
exposure helps patients learn that their feared situations and thoughts do not
objectively pose a high risk of threat. Response prevention helps the patient learn that
time-consuming and embarrassing rituals are not necessary to prevent feared
outcomes. In fact, when the rationale for CBT is clear and the treatment plan is set up
collaboratively, doing this treatment prompts a supportive and highly rewarding
working relationship which helps the patient make considerable and long-lasting
progress.
5
Case Vignettes
This chapter presents examples of fear hierarchies and treatment plans (session-by-
session descriptions of situational and imaginal exposure tasks) for common
presentations of OCD. CBT in each of these four cases resulted in marked reductions in
symptoms, dramatic diminution in ritualistic behaviors, and significant enhancement of
each patient’s ability to cope with distressing and intrusive thoughts. You can use these
vignettes as templates for building CBT programs for your patients.
Case 1: Contamination Symptoms
Kristi, a 36-year-old hotel manager, feared contracting the herpes virus. She avoided
public bathrooms and contact with surfaces such as door handles and garbage cans. She
also avoided contact with other people and their belongings (pens, office telephones,
etc.). Bodily waste and secretions such as urine, feces, and sweat also evoked obsessive
fear. Kristi washed her hands over 50 times each day and often showered and changed
her clothes multiple times to reduce her fears of contamination.
Kristi’s fear hierarchy was as follows:
Hierarchy Item

Door handles and hand rails

Images of “herpes germs”
Shaking hands with others
Public telephones
Images of getting cold sores from herpes
Garbage cans
Sweat
Images of becoming terribly ill
Public bathrooms
Urine
Feces
Kristi’s response prevention plan was as follows:
• No contact with water except for one 10-minute shower and one 2-minute tooth
brushing each day. Immediately after contact with water, she was to re-expose herself
to stimuli from the fear hierarchy.
• No changing of clothes after dressing for the day.
During the first exposure session, Kristi and the therapist walked through the clinic and
touched door handles and hand rails, maintaining contact with each for a period of
several minutes. In the therapist’s office, Kristi described her intrusive images of
“herpes germs” crawling all over her body into a tape recorder and listened to the tape
repeatedly for imaginal exposure. Between sessions, she conducted daily self-exposures
to door handles and other surfaces in places that she had been avoiding, such as work
and certain stores. She also practiced imaginal exposure using the recorded material.
At the second session, Kristi practiced shaking hands with clinic staff (strangers). She
also touched public telephones, concentrating on the receiver since she was concerned
about germs from other peoples’ mouths. Imaginal exposure involved distressing
images of cold sores, uncertainty about where people might have put their hands, and
who might have used the telephones she touched. Between sessions, she practiced
shaking hands and touching public phones, especially before eating.
During the third session, Kristi practiced touching garbage cans, especially those in
public areas such as malls. Imaginal exposure to images of germs was continued, and
Kristi practiced eating with her hands immediately after contact with trash cans. She
repeated these and similar exercises each day between the third and fourth sessions.
At the fourth session, exposure to sweat was conducted by having Kristi run in place
and then put one hand under her arm and the other inside her shoe. Imaginal exposure
involved thinking of becoming ill from “sweat germs.” Kristi kept a soiled sock in her
pocket between sessions. She handled the sock each time before she ate.
Public bathrooms were the focus of session 5. Kristi confronted bathroom door handles,
sink faucets, and soap dispensers by maintaining contact with these items for several
minutes. She confronted toilets by sitting next to the bowl and touching the flusher and
seat. For practice between sessions, she was instructed to sit on public toilets in various
places she had been avoiding (e.g., mall bathrooms). Imaginal exposure included images
of germs, cold sores, and of becoming ill.
Session 6 again involved a supervised public bathroom exposure. After touching the
toilet, urine was confronted by having Kristi hold a paper towel dampened with a few
drops of her own urine specimen collected earlier that day. Between sessions, Kristi
carried the paper towel in her pocket and frequently touched it to her hands.
At session 7, exposure included public toilets and urine, with the introduction of feces (a
piece of toilet paper lightly soiled with her own excrement). Kristi was instructed to
practice with feces, urine, and toilet seats between sessions.
Sessions 8 through 16 included repeated exposures to public bathrooms, urine, and
feces—which provoked the greatest discomfort. She practiced eating and touching
personal items (e.g., her purse) immediately following these exposures. Imaginal
exposure to distressing thoughts and periodic contact with lesser contaminants was
continued. Kristi was also encouraged to contaminate additional personal items at home
and at work.
Case 2: Harming Symptoms
Steve, a 33-year-old real estate agent, performed checking rituals that were precipitated
by thoughts that he could become responsible for injury to others and their property. If
he saw a fire truck or ambulance, he worried that perhaps he had started a fire or
caused an accident without realizing it. He watched the TV news, scoured the
newspapers, and even checked with police to ensure he had not caused such disasters.
He often returned to houses he had shown to potential buyers to make sure all
appliances were off and doors locked. After his wife and children went to sleep each
night, Steve spent hours checking the electrical appliances, door locks, windows, and
water faucets in his home; and the parking brake of his car.
Steve’s fear hierarchy was as follows:
Hierarchy Item

Turn light switch on and off

Images of fires
Open and close window
Open/close car door and enable/disable parking break
Images of accidents
Turn appliances on and off
Turn water faucet on and off
Steve’s response prevention plan was as follows:
• No checking doors, windows, appliances, the car,
• No seeking reassurance by asking other people (e.g., family, police officers) about
disasters.
• No returning to other homes to check for safety.
• No watching the news or reading the local section of the newspaper to look for
possible disasters.
The first treatment session began at Steve’s home where all of the lights were first
turned on. Then, Steve quickly went through the house (unsupervised by the therapist)
and turned the lights off without checking (no one else was home at the time). He then
left the house and drove away. For imaginal exposure, Steve practiced thinking about
house fires that might have started from leaving lights on in the house. Each day
between the first and second sessions, Steve practiced this exercise after his wife and
children had left the house for the day.
The second session was also held at Steve’s house. Exposure involved opening and
closing windows on the ground floor without checking, followed by quickly leaving the
house. Again, between sessions, Steve practiced this exercise while his family was out
for the day.
At the third session, situational exposure involved Steve and the therapist driving
around the block in Steve’s car, rolling down the windows, and unlocking the doors.
After arriving back at the clinic, Steve turned off the car engine, applied the parking
break, rolled up the windows, and locked the car doors before quickly evacuating the
car and, without checking, walking into the clinic building. Secondary imaginal exposure
to thoughts about the feared consequences of leaving the parking break off, windows
down, and doors unlocked, was conducted once in the therapist’s office. Steve practiced
similar exercises each day between sessions 3 and 4. During session 4, primary imaginal
exposure to thoughts of unknowingly causing accidents was added to the situational
exposure. Between sessions, Steve practiced these tasks.
Sessions 5 and 6 took place in Steve’s home. During session 5, in addition to windows
and lights, exposure included practice turning appliances on and off and then leaving
the house without checking. Steve conducted secondary imaginal exposure to images of
house fires for which he was responsible because of the failure to check. At session 6,
turning water faucets on and off was added to the exposure tasks. Between sessions,
assignments included daily repetitions of these same exercises.
Sessions 7 through 16 focused on conducting exposures in different contexts. For
example, Steve and the therapist visited several homes for sale. Steve practiced turning
lights and appliances on and off in each home, and then leaving the home and
conducting imaginal exposures to thoughts of causing fires. Between sessions, he also
practiced turning lights and appliances on and off, and unlocking and locking doors and
windows, before going to bed in his own home.
Case 3: Incompleteness Symptoms
Jill, a 26-year-old woman who lived with her parents, engaged in ordering, arranging,
and balancing rituals triggered by distressing obsessional thoughts of “imperfection”
and “imbalance.” Activities such as completing paperwork often took hours because Jill
had to painstakingly make sure that letters were formed correctly and “perfectly.” Items
in the house had to be arranged in certain ways and Jill had to ensure that such order
was maintained. Her most pervasive symptoms focused on left-right balance. For
example, if she used her right hand to open a door or to grab something (e.g., from the
refrigerator), she felt an urge to repeat the behavior using her left hand (and vice versa)
to achieve balance. These symptoms limited Jill’s ability to function to the point that on
many days she was unable to leave the house.
Jill’s fear hierarchy was as follows:
Hierarchy Item

Write letters “Imperfectly”

Write imperfectly in checkbook
Leave items in the family room “out of order”
Leave items in own room “out of order”
Say, write, and hear the word “left” without the word “right”
“Notice” left-right imbalance
Touch items on right (or left) side only
Jill’s response prevention plan was as follows:
• No re-writing.
• No ordering/arranging
• No attempts to achieve left-right balance visually, verbally, motorically, or otherwise
At session 1, Jill practiced writing letters imperfectly (e.g., sloppily); first on blank pieces
of paper, then on notes she was sending to others, and finally on paperwork such as
financial statements. This was also practiced between sessions.
Session 2 began with more practice writing imperfectly, this time culminating with Jill
filling out her checkbook imperfectly. Homework exposure involved writing imperfectly
(e.g., sloppily)
At the third and fourth sessions, Jill practiced rearranging items in the therapist’s office
so that they were “not balanced.” For example, she tilted the therapist’s picture frames
slightly to the right and shifted books on the bookshelves to the right. Jill’s homework
assignments involved gradually rearranging items in her own home so that they seemed
“out of order.” This began with items in the living room and eventually involved items in
her bedroom. Jill was instructed to remind herself that these items were “out of order,”
but to also refrain from urges to re-arrange them the “correct” way.
The fifth session involved confrontation with the word “left” in the absence of the word
“right.” Jill practiced saying “left” and even writing it on the back of both of her hands.
Homework exposure involved further exposure to “left.” She also kept a piece of paper
with this word in her pocket at all times.
Session 6 involved continued exposure to the word “left,” as well as to purposely
noticing left-right imbalance and not performing any “balancing” rituals. Jill and
therapist walked though the clinic and purposely noticed unevenness (e.g., elevator
buttons on the right side of the elevator, the fact that more people were sitting on the
right side of the waiting room than on the left side). Jill also purposely brushed against
objects such as walls and desks on her left or her right side without “balancing” this out.
She completed similar exposures between sessions. In addition, she was instructed to
leave her belt buckle slightly off center (facing left) and to tie her left shoe noticeably
more tightly than her right shoe.
Sessions 7 through 16 involved repeated exposure to left-right imbalance in various
contexts. For example, Jill created this imbalance in her bedroom and encouraged her
parents to do the same in various parts of the house.
Case 4: Unacceptable Thoughts
Matt, was a devoutly religious 25-year-old married (heterosexual) graduate student
with recurrent unwanted homosexual thoughts and images. These obsessions were
triggered by hearing certain words (e.g., “penis”) and by the sight of certain men—
especially Matt’s friend, Todd. Matt was avoiding spending time with his male friends
and had stopped going to the gym, where he might see other men undressed in the
locker room. He was also avoiding sexual intercourse with his wife because the
homosexual thoughts had once occurred during sex. Matt feared that the frequency and
intensity of his obsessions indicated that he was “turning gay”; something that was
strictly forbidden from his religious viewpoint. When the thoughts came to mind, he
tried to “analyze” their meaning and often “tested” himself by looking at (or thinking of)
attractive women to reassure himself that he was still heterosexual. These mental
rituals sometimes lasted for hours each day. Matt also prayed ritualistically that he was
not becoming gay.
Matt’s fear hierarchy was as follows:
Hierarchy Item

Words (“gay” “penis” “homosexual”)

Pictures of handsome men (models)
Pictures of Todd
Mental images of Todd’s penis
Gym/locker room
Homoerotic pornography
Images of having sex with other men
Sexual intercourse with wife
Matt’s response prevention plan was as follows:
• No mental analyzing of the meaning of thoughts
• No “testing” for reassurance of heterosexuality
• Refrain from any prayers about intrusive thoughts
During the first exposure session, Matt practiced saying the words “penis,” “gay,”
“homosexual,” “anal sex,” and “blow job,” which were anxiety-provoking for him. He also
repeatedly wrote these words on sheets of paper that he kept in his wallet. Homework
practice included repeating these exercises daily.
At session 2, Matt viewed pictures of attractive men by looking through fitness and
fashion magazines. He was instructed to discuss of how good-looking he thought these
men were. He also took the magazines home so that he could repeat this task between
sessions.
During the third session, Matt looked at pictures of his friend Todd for exposure. For
imaginal exposure, he visualized what Todd would look like nude, including having
images of his penis. Matt was instructed to repeat this exercise each day between
sessions, and to expose himself imaginally to the doubts about his sexual preference
that this exercise evoked.
Exposure to watching men in the fitness club during the fourth exposure session was
engineered as follows: Matt and the therapist met at the gym during the busiest time of
day. They stood on the balcony above the weight room and the therapist instructed Matt
to notice and remark about men’s physiques. Matt went into the men’s locker room and
struck up a conversation with a man who was undressed and preparing to take a
shower. During the brief conversation, Matt surreptitiously noticed the man’s naked
body, as the therapist had coached him to do. Matt repeated this exposure several times
between sessions.
During the fifth session, Matt viewed explicit pornographic images and films of men
engaged in autoerotic and homosexual activity. He repeated these exposures between
sessions.
At the sixth session, Matt again practiced viewing images of homosexual activity. To
confront images of having sex with other men, he wrote a story describing himself
engaged in such activities with his friend, Todd. Matt was instructed to vividly describe
the events. He wrote similar stories between sessions.
During sessions 7 to 16, Matt practiced viewing more homoerotic pornography and
writing additional stories about sexual encounters between himself and other men.
These “fantasies” were varied according to what evoked greater distress; for example,
the use of more intense and graphic imagery. Matt also was instructed to resume
intercourse with his wife and to resist urges to dismiss any intrusive homosexual
thoughts that came to mind.
6
Further Reading
This section includes key references to literature where the practitioner can find further
details or background information. Each reference includes a brief (2–5 lines)
annontation.
Abramowitz, J. (2006). Understanding and treating obsessive-compulsive disorder: A cognitive-
behavioral approach. New York: Lawrence Erlbaum Associates.
Presents didactic material on the clinical features and psychological theories of OCD. Also contains a
manual for cognitive-behavioral assessment and treatment.
Abramowitz, J., Franklin, M., & Cahill, S. (2003). Approaches to common obstacles in the exposure-
based treatment of obsessive-compulsive disorder. Cognitive and Behavioral Practice, 10, 14–22. This
article discusses a number of problems that can arise during CBT for OCD. Case examples are
presented and suggestions for managing these problems are described.
Clark, D. (2004). Cognitive-behavioral therapy for OCD. New York: Guilford. This book provides the
reader with an in-depth review of OCD symptoms and theories, emphasizing cognitive theory. The
use of cognitive therapy techniques for OCD is also outlined in manual form.
7
References
Abramowitz, J. (1998). Does cognitive-behavioral therapy cure obsessive-compulsive disorder? A
Meta-analytic evaluation of clinical significance. Behavior Therapy, 29, 339–355.
Abramowitz, J. S. (1996). Variants of exposure and response prevention in the treatment of
obsessive-compulsive disorder: A meta-analysis. Behavior Therapy, 27, 583–600.
Abramowitz, J. S. (1997). Effectiveness of psychological and pharmacological treatments for
obsessive-compulsive disorder: A quantitative review. Journal of Consulting and Clinical Psychology,
65(1), 44–52.
Abramowitz, J. S., Franklin, M. E., & Foa, E. B. (2002). Empirical status of cognitive-behavioral therapy
for obsessive-compulsive disorder: A meta-analytic review. Romanian Journal of Cognitive and
Behavioral Psychotherapies, 2(2), 89–104.
Abramowitz, J. S., Franklin, M. E., Schwartz, S. A., & Furr, J. M. (2003). Symptom presentation and
outcome of cognitive-behavioral therapy for obsessive-compulsive disorder. Journal of Consulting
and Clinical Psychology, 71(6), 1049–1057.
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th
ed., Text revision) (DSM-IV-TR). Washington, DC: Author.
Beck, A. T., Epstein, N., Brown, G. & Steer, R.A. (1988). An inventory for measuring clinical anxiety:
psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893–897.
Beck, A. T., Ward, C. H., Medelsohn, M., Mock, J., & Erlbaugh, J. (1961). An inventory for measuring
depression. Archives of General Psychiatry, 4, 561–571.
Crino, R. D., & Andrews, G. (1996a). Obsessive-compulsive disorder and Axis I comorbidity. Journal of
Anxiety Disorders, 10(1), 37–46.
Crino, R. D., & Andrews, G. (1996b). Personality disorder in obsessive compulsive disorder: A
controlled study. Journal of Psychiatric Research, 30(1), 29–38.
Di Nardo, P., Brown, T., & Barlow, D. H. (1994). Anxiety Disorders Interview Schedule for DSM-IV:
Lifetime Version (ADIS-IV-LV). San Antonio, TX: The Psychological Corporation.
Eisen, J. L., Phillips, K. A., Baer, L., Beer, D. A., Atala, K. D., & Rasmussen, S. A. (1998). The Brown
Assessment of Beliefs Scale: Reliability and validity. American Journal of Psychiatry, 155(1), 102–108.
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. (2002). Structured Clinical Interview for the DSM-
IV Axis 1 Disorders. New York, NY: Biometrics Research Department, new York State Psychiatric
Institute.
Foa, E., & Kozak, M. (1986). Emotional processing of fear: exposure to corrective information.
Psychological Bulletin, 99, 20–35.
Foa, E., Liebowitz, M. R., Kozak, M. J., Davies, S., Campeas, R., Franklin, M. E., et al. (2005).
Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their
combination in the treatment of obsessive-compulsive disorder. American Journal of Psychiatry, 162,
151–161.
Foa, E. B., Huppert, J. D., Leiberg, S., Langner, R., Kichic, R., Hajcak, G., & Salkovskis, P. M. (2002). The
Obsessive-Compulsive Inventory: Development and validation of a short version. Psychological
Assessment, 14, 485–496.
Foa, E. B., & Kozak, M. J. (1996). Psychological treatment for obsessive-compulsive disorder. In M. R.
Mavissakalian & R. F. Prien (Eds.), Long-term treatments of anxiety disorders (pp. 285–309).
Washington, DC: American Psychiatric Press, Inc.
Franklin, M. E., Abramowitz, J. S., Foa, E. B., Kozak, M. J., & Levitt, J. T. (2000). Effectiveness of
exposure and ritual prevention for obsessive-compulsive disorder: Randomized compared with
nonrandomized samples. Journal of Consulting and Clinical Psychology, 68(4), 594–602.
Frost, R. O., & Steketee, S. (2002). Cognitive approaches to obsessions and compulsions: Theory,
assessment, and treatment. Oxford: Elsevier.
Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Delgado, P., Heninger, G. R., et al. (1989).
The Yale-Brown Obsessive Compulsive Scale: validity. Archives of General Psychiatry, 46, 1012–1016.
Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., Hill, C. L., et al. (1989).
The Yale-Brown Obsessive Compulsive Scale: Development, use, and reliability. Archives of General
Psychiatry, 46, 1006–1011.
Gross, R. C., Sasson, Y., Chorpa, M., & Zohar, J. (1998). Biological models of obsessive-compulsive
disorder: The serotonin hypothesis. In R. P. Swinson, M. Antony, S. Rachman & M. Richter (Eds.),
Obsessive-compulsive disorder: Theory, research, and treatment (pp. 141–153). New York: Guilford.
Hamilton, M. (1960). A rating scale for depression. Journal of Neurological and Neurosurgical
Psychiatry, 18, 315–319.
Hiss, H., Foa, E. B., & Kozak, M. J. (1994). Relapse prevention program for treatment of obsessive-
compulsive disorder. Journal of Consulting and Clinical Psychology, 62(4), 801–808.
Karno, M., Golding, J., Sorenson, S., & Burnam, A. (1988). The epidemiology of obsessive-compulsive
disorder in five US communities. Archives of General Psychiatry, 45, 1094–1099.
Kozak, M. J., & Coles, M. E. (2005). Treatment of obsessive-compulsive disorder: Unleashing the
power of exposure. In J. S. Abramowitz & A. C. Houts (Eds.), Concepts and controversies in obsessive-
compulsive disorder (pp. 283–304). New York: Springer.
McKay, D., Abramowitz, J. S., Calamari, J. E., Kyrios, M., Radomsky, A. S., Sookman, D., et al. (2004). A
critical evaluation of obsessive-compulsive disorder subtypes: Symptoms versus mechanisms.
Clinical Psychology Review, 24, 283–313.
McNally, R. J. (2000). Information-processing abnormalities in obsessive-compulsive disorder. In W.
K. Goodman, M. V. Rudorfer, & J. D. Maser (Eds.), Obsessive-compulsive disorder: Contemporary issues
in treatment. (pp. 105–116). Mahwah, NJ: Lawrence Erlbaum Associates, Inc.
Mowrer, O. (1960). Learning theory and behavior. New York: Wiley.
Rachman, S., & Hodgson, R. (1980). Obsessions and compulsions. Englewood Cliffs, NJ: Prentice Hall.
Saxena, S., Bota, R. G., & Brody, A. L. (2001). Brain-behavior relationships in obsessive-compulsive
disorder. Seminars in Clinical Neuropsychiatry, 6, 82–101.
Shafran, R. (2005). Cognitive-behavioral models of OCD. In J. S. Abramowitz & A. C. Houts (Eds.),
Concepts and controversies in obsessive-compulsive disorder. New York: Springer.
Williams, K., Chambless, D. L., & Steketee, G. (1998). Behavioral treatment of obsessive-compulsive
disorder in African Americans: Clinical issues. Journal of Behavior Therapy & Experimental Psychiatry,
29(2), 163–170.
8
Appendix: Tools and Resources
This appendix contains tools and resources that therapists can copy and give to
patients. These include a functional assessment form, a fear hierarchy form, a self-
monitoring form, a hand-out on intrusive thoughts, guidelines for successful exposure,
and an exposure practice form.
Functional Assessment of OCD Symptoms
Date:

Patient Name: _________________

Date of birth: __________________
Educational level: _______________

_____________________________________________________________________________
Obsessional Stimuli
• External triggers of obsessions (people, places, things, and situations that evoke
anxiety; e.g., mold, leaving home, “13”)

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
• Obsessional thoughts, impulses, images, doubts (e.g., “God is dead”, images of
germs, impulse to harm, doubts about fires)

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Cognitive Features
• Feared consequences of exposure to obsessional triggers (e.g., “I will get sick if I
don’t wash my hands”)

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
• Catastrophic interpretations of intrusive thoughts (e.g., “thinking about it is the
same as doing it”)

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
• Fears of long-term anxiety/discomfort (“I will be anxious forever unless I
ritualize”)

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Responses to Obsessional Distress (Safety-Seeking Behaviors)
• Passive avoidance (identify its relationship to obsessional fear; e.g., avoids old
buildings due to fears of asbestos)

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
• Overt compulsive rituals (identify relationships to obsessional fear; e.g., checks the
door to prevent burglary; reassurance seeking)

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
• Mental rituals, covert neutralizing strategies (e.g., thought suppression, mental
reviewing, using positive images; identify relationships to obsessional fear)

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Self-Monitoring of OCD Symptoms
Ritual 1: ________________________

Date

Everyone Has Intrusive Thoughts

In obsessive-compulsive disorder (OCD), obsessions are defined as unwanted intrusive
thoughts, ideas, or images that trigger anxiety, fear, or discomfort. The content of
obsessions is often senseless or bizarre. The themes of obsessions often concern harm,
violence, aggression, sex, religion, mistakes, physical appearance, germs, diseases, need
for exactness, among other things. Because obsessions evoke anxiety and distress,
people usually try to resist, stop, or control these intrusive thoughts. But this often
doesn’t work, or perhaps it works only for a short time. Then, the thought returns and
can develop a “life of its own.”
What many people do not realize is that practically everyone experiences unwanted
intrusive thoughts (whether or not they have OCD). These sorts of thoughts are part of
normal human thinking. The focus of this handout is to teach you that the unpleasant,
distressing, repugnant, bizarre, and senseless obsessional thoughts that you are
experiencing are not at all dangerous or abnormal.
Intrusive Thoughts Are Normal
Everyone knows the experience of senseless intrusive thoughts. Whether it is a
daydream about winning the lottery, a frightening image of harm or danger, or a
senseless doubt that is completely opposite of how you usually think, all humans have
senseless and unwanted thoughts. You may be surprised to learn that even the kinds of
intrusive, upsetting, unacceptable unwanted thoughts that resemble obsessions in OCD
are experienced by just about everyone in the world. That is, people without OCD
experience the same kinds of unwanted and intrusive thoughts as do people with OCD. The
list below shows examples of intrusive thoughts reported by people without OCD:
• Thought of jumping off the bridge onto the highway below
• Thought of running car off the road or onto oncoming traffic
• Thought of poking something into my eyes
• Impulse to jump onto the tracks as the train comes into the station
• Image of hurting or killing a loved one
• Idea of doing something mean towards an elderly person or a small baby
• Thought of wishing that a person would die
• Impulse to run over a pedestrian who walks too slow
• Impulse to slap someone who talks too much
• Thought of something going terribly wrong because of my error
• Thought of having an accident while driving with children
• Thought of accidentally hitting someone with my car
• Image of loved one being injured or killed
• Thought of receiving news of a close relative’s death
• Idea that other people might think that I am guilty of stealing
• Thought of being poked in eye by an umbrella
• Thought of being trapped in a car under water
• Thought of catching diseases from various places such as a toilet
• Thought of dirt that is always on my hand
• Thought of contracting a disease from contact with person
• Urge to insult friend for no apparent reason
• Image of screaming at my relatives
• Impulse to say something nasty or inappropriate to someone
• Impulse to do something shameful or terrible
• Thought that I left door unlocked
• Thought of my house getting broken into while I’m not home
• Thought that I left appliance on and cause a fire
• Thought of sexually molesting young children
• Thought that my house burned and I lost everything I own
• Thought that I have left car unlocked
• Thought that is contrary to my moral and religious beliefs
• Hoping someone doesn’t succeed
• Thoughts of smashing a table full of crafts made of glass
• Thoughts of acts of violence in sex
• Sexual impulse toward attractive females
• Thought of “unnatural” sexual acts
• Image of a penis
• Image of grandparents having sex
• Thought about objects not arranged perfectly
Why do all people get these kinds of intrusive thoughts? This is probably because as
humans we have highly developed and creative brains that can imagine all kinds of
scenarios—some more pleasant than others. Sometimes, our “thought generator”
produces thoughts about danger even though there may not be any real threat present.
Humans have many thoughts while awake and during sleep, so it would be expected
that our brains will sometimes create bizarre or senseless thoughts (“mental noise”).
Often, such thoughts are triggered by actual situations, such as the sight of a knife,
bathroom, driving, or a religious icon.
Scientists have conducted many studies on unwanted intrusive thoughts in people with
and without OCD. All of these studies confirm that people with and without OCD have
the same kinds of intrusive thoughts. In the most well-known study, researchers asked
people with OCD and people without OCD to list some of their unpleasant unwanted
thoughts. The lists (which resembled the list of thoughts shown above) were then given
to psychologists and psychiatrists who were asked to say which thought came from
people with and without OCD. But most of the time, even these professionals could not
tell whether the thought was a clinical obsession from someone with OCD or a “normal
obsession” from a nonOCD person.
This study (and several others like it) confirms that people with OCD do not have
something abnormal in their brain that causes them to have terrible, senseless, or
immoral obsessive thoughts. Instead, obsessions in OCD (even the most unacceptable,
disgusting, violent, depraved thoughts and images) develop from entirely normal
experiences as we will explore in this handout.
Differences Between “Normal” and “OCD” Obsessions
Researchers have found some important differences between “normal” obsessions and
clinical (OCD) obsessions. In particular:

1. OCD obsessions are more distressing than normal obsessions,

2. OCD obsessions are resisted more strongly than are normal obsessions, and,
3. OCD obsessions are more repetitive than normal obsessions,
The rest of this handout will explain these differences so that you understand how the
distressing (anxiety-provoking), recurring, and intense OCD obsessions develop from
normal everyday intrusive thoughts (normal obsessions).
A. Why are OCD obsessions distressing?
Although everyone has unwanted distressing intrusive thoughts, it turns out that people
have different ways of interpreting the meaning of these kinds of thoughts. When such
thoughts are interpreted as especially threatening, it causes the thoughts to evoke fear,
anxiety, and distress.
Let’s look at how people with and without OCD interpret their intrusive unwanted
thoughts. Research shows that people without OCD dismiss their intrusive unwanted
thoughts as “mental noise”. They recognize that such thoughts (even thoughts about
disturbing things) are normal and meaningless. For example, a person without OCD who
experiences a unwanted thought might say to him or herself, “that’s a silly thought, I
would never do that,” or “that thought doesn’t make any sense.” When this happens, the
person doesn’t pay any more attention to the thought, and the thought soon passes
without difficulty.
On the other hand, people with OCD tend to misinterpret these normal intrusive
thoughts as very meaningful, significant, and threatening or dangerous. For example:

• “It is bad to have this kind of thought”

• “If I am thinking of something bad, it must be true”
• “If I think of something awful, it means I am an awful person”
• “If I have bad thoughts, it means I am losing my mind or that I will do something
terrible”
When a person interprets his or her own thoughts as dangerous or threatening, this is
what makes him or her feel distressed and anxious. After all, if you really believe that
having certain unwanted thoughts means that something bad is about to happen, it
would be normal to feel afraid. However, it is important to see that the real problem is
the mistaken interpretation of the intrusive thought, not the thought itself. The thought
is a normal experience. It is not actually harmful. Misinterpreting normal intrusive
thoughts as dangerous makes the thoughts become distressing.
B. Why are OCD obsessions resisted?
Misinterpreting certain unwanted intrusive thoughts as dangerous leads not only to
distress, but it also makes you want to resist or push the thought out of your mind. You
can probably see how someone would try to resist an intrusive upsetting negative
thought if they interpreted this thought to be significant, important, or dangerous.
C. Why are OCD obsessions repetitive?
People with OCD report that their intrusive obsessional thoughts are repetitive (they
occur more frequently than do normal obsessions). Sometimes such thoughts are
triggered by reminders in the environment, but at other times, they just seem to pop up
from “out of the blue.” The repetitiousness of obsessions also has a lot to do with how a
person interprets these kinds of thoughts.
Specifically, once an intrusive thought is interpreted as threatening, it activates the
body’s automatic danger detection system (the “fight-flight” system) which causes the
person to become hyper alert and “on guard” for the perceived threat. This is a normal
and adaptive response whenever threat is perceived because it helps protect us from
danger. For instance, if you had to walk across a busy street, your “fight or flight”
response would kick in and you would become very aware of the cars coming toward
you. You would scan the road for cars so that you could run out of the way to safety
(flight) if you had to.
In the case of OCD obsessions, the perceived threat is an otherwise normal intrusive
thought that has simply been misinterpreted as threatening. These misinterpretations
lead people with OCD to become hyper-aware of (preoccupied with) their unwanted
thoughts as if they were truly dangerous (which, as we have seen, is not at all the case).
This natural tendency to become preoccupied with intrusive thoughts that are
considered dangerous helps to explain the repetitiveness of obsessions in OCD.
There are other ways that people with OCD respond to their intrusive thoughts that can
increase the repetitiveness of obsessions. For example, humans are not very good at
controlling their thoughts. So, trying to push unwanted thoughts out of your head
(called thought suppression) actually leads to an increase in the unwanted thought. This
is a normal phenomenon—just see what happens if you try not to think of a pink
elephant. If you have intrusive thoughts that you have misinterpreted as dangerous,
leading you to try to force the thoughts out of your mind, you will probably end up with
more of the bad thought (leading to a vicious cycle of more anxiety and futile attempts
to suppress, and so on).
Conclusions
In conclusion, it is important to realize that everyone has intrusive, unwanted, upsetting
thoughts from time to time. These thoughts are normal. They do not suggest any danger,
evil, perversion, immorality, etc. They are simply senseless thoughts. The major
difference between people with and without OCD is in how these kinds of thoughts are
interpreted or appraised. People with OCD misinterpret these thoughts as significant,
meaningful, and dangerous. This leads to anxiety and distress. It also makes the
thoughts seem to take on a “life of their own.” One aim of treatment for OCD is to help
you learn how to properly regard these thoughts as “mental noise” so that they no
longer cause obsessional problems.
Cognitive Distortions in OCD
1. Intolerance of Uncertainty: Need for a 100% guarantee of safety (absolute
certainty). Any hint of doubt or ambiguity is interpreted to mean a negative outcome is
probable.
2. Overestimation of Threat: Exaggerating (a) the probability of negative outcomes,
and/or (b) the seriousness of negative consequences.
3. Overestimation of Responsibility: Believing that one holds the power to prevent
negative outcomes. Also, believing that the failure to prevent harm is the same as
causing harm.
4. Significance of Thoughts: Believing that senseless, intrusive, and unwanted
thoughts are important or very meaningful in one way or another.
– Moral Thought-Action Fusion: Belief that thoughts are morally equivalent to
behaviors.
– Likelihood Thought-Action Fusion: Belief that thinking about something bad will
lead to the corresponding action or event.
5. Need to Control Thoughts: Believing that one can and should control unwanted bad
thoughts; and that they must do so to prevent negative outcomes.
6. Intolerance of Anxiety: Believing that anxiety or discomfort could persist forever or
spiral out of control and lead to “going crazy,” or other harmful consequences.
7. The “Just Right” Error (Perfectionism): The sense that things must be “just right,”
even, orderly, or perfect in order to feel comfortable.
8. Emotional reasoning: Assuming that danger is present based simply on the fact that
you are feeling anxious (“If I feel anxious, there must be danger”).
Fear Hierarchy Form
Situational Exposure Items
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8.
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10.
11.
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14.
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16.
17.
18.
19.
20.
Imaginal Exposure Items
1.
2.
3.
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8.
The 10 Commandments for Successful Exposure
1. Exposure practices should be planned and structured. Prepare for the exercise in
advance to make sure that it is conducted properly.
2. Exposure practices should be repeated frequently. Practice the same exposure
tasks over and over until they become easier and provoke minimal distress.
3. Do Exposure gradually. Begin with exposure tasks that provoke only moderate
levels of distress and work up to more difficult tasks.
4. Expect to feel uncomfortable. Exposure tasks must initially evoke discomfort to be
successful. This discomfort is temporary and it will subside as you remain in the task
and as you repeat the task.
5. Don’t fight the discomfort. You will not benefit from exposure if you fight the
anxiety (you might as well not do the task at all). Instead, just let yourself feel anxious.
The worst thing that can happen is that you will temporarily feel uncomfortable.
6. Don’t use subtle avoidance strategies. Complete exposure practices without using
distraction, anti-anxiety medication, alcohol, and other such strategies.
7. Use exposure practices to test negative predictions about the consequences of
facing your fear. Before starting the exposure, think about what you are afraid might
happen during the task. Afterwards, review what you learned from the exposure and
how it compares to your original fearful prediction. Did the worst possible thing
happen? How did you manage?
8. Keep track of your fear level. Pay attention to how you are feeling during the
exposure task. Take note of your anxiety level at regular intervals and rate your fear
level from 0–100.
9. Exposure should last until anxiety has significantly declined. Continue the
exposure until anxiety goes down by at least 40% to 50%.
10. Practice exercises by yourself. It is helpful to conduct some exposures by yourself
because the presence of other people can sometimes make us feel artificially safe.
Exposure Practice Form

Name: ____________________Date:______________Time:____________

Session Number:___________________________
1. Description of the exposure exercise:
__________________________________________________________________________
__________________________________________________________________________
2. Feared outcome of exposure:
__________________________________________________________________________
__________________________________________________________________________
3. Estimated probability of the feared outcome (0–100%): ____________ %
4. Estimated severity of the feared outcome (0–100%): ____________ %
5. Every ____ minutes during the exposure, rate SUDS from 0 to 100:
• SUDS when beginning exposure (0–100) _________

SUDS
1.________
2.________
3.________
4.________
5.________
6.________

6. Describe the outcome of the exposure. What was learned?

__________________________________________________________________________
__________________________________________________________________________
7. Revised probability estimate: (0–100%): ____________ %
8. Revised severity estimate: (0–100%): ____________ %