ocd flow chart explanation

based on the OCD model in:

Wells A Cognitive therapy of anxiety disorders Chichester: Wiley, 1997
trigger/intrusion: Obsessive compulsive disorder (OCD) is a common
psychological problem which responds well to effective therapy. The flow chart
illustrates how OCD symptoms are typically triggered by intrusive thoughts, doubts
or occasionally emotions.
background beliefs about the intrusion: Background beliefs about
intrusive thoughts determine the meaning and importance given to the intrusion.
These background beliefs govern how much attention is paid to the intrusion and
how it is responded to. When experiencing obsessive thoughts, OCD sufferers
frequently blur the boundary between internal thoughts and external reality. This
blurring of the internal thought/ external reality boundary involves background
beliefs such as “Having this thought means I have probably carried out the action
depicted in the thought.” or “Having this thought means the event depicted in the
thought has probably occurred.” These thought-action fusion and thought-event
fusion beliefs may well seem foolish to an OCD sufferer most of the time. However
when one is anxious and the mind is filled with obsessive thoughts such fusion
beliefs are hard to challenge. Further troublesome background beliefs may involve
fears about possible damaging consequences of disturbing emotions and feelings.

assessment of intrusion: Overall beliefs about intrusive thoughts and

feelings determine the assessment of the intrusion. Is the intrusive thought
assessed as important enough to pay attention to, take seriously, and respond to in
some way? Or is the intrusive thought judged to be trivial, unimportant, just a
passing notion that has floated into the mind and can simply be left to float out
again?

beliefs about rituals: Interacting with the assessment of intrusive thoughts

or feelings are beliefs about rituals and behavioural responses. These beliefs can
be either positive or negative. Positive beliefs about rituals evaluate such
behaviours as largely beneficial. Exam-ples include beliefs like “If I wash without
thinking a bad thought, bad things won’t happen” or “If I perform my ritual, I know
I will feel a lot better.” Negative beliefs about rituals judge these behaviours as
unhelpful or possibly harmful – for example “My rituals are out of control” or
“Mental rituals could damage my body.”

emotional reactions: As illustrated in the flow chart, two feedback loops can
operate from emotional reactions caused by intrusions and rituals. Emotional
reactions may feedback to influence assessment of the intrusion itself. For
example anxiety symptoms may be mis-interpreted as a sign of loss of control or of
some other fear associated with the intrusion. A second feedback loop links
emotional reactions to the initial trigger/intrusion. This connection can increase the
likelihood of the whole cycle repeating again. For example anxiety tends to
increase scanning for further intrusions, boosts the attention that one gives to an
intrusion, and increases the accessibility of memories linked to similar emotional
experiences in the past. Furthermore the emotional reaction may act as a trigger
in its own right, setting off fears of being overwhelmed by negative feelings.

rituals and behavioural responses: Rituals and behavioural responses

can be external or internal. External rituals include physical checking, washing,
cleaning, and ordering. Internal rituals include checking thoughts, memories &
feelings, repeating, counting, thought suppression, rumination, and trying to
control one’s mind. Rituals frequently ease distress in the short term.
Unfortunately they typically aggravate the problem in the longer term. It’s a bit
like an alcoholic taking a drink to help themself feel better. It may work at the
time, but it actually contributes to keeping the whole problem going. This is
[Cont.]
illustrated again in the flow chart by a couple of feedback loops. The more direct
loop links rituals to beliefs about rituals and the assessment of intrusions. The OCD
sufferer may well believe that the ritual prevents disastrous consequences from
occurring. Of course by perform-ing the ritual the sufferer never learns properly
that the feared disaster is just a fear and not a reality. The ritual or safety
behaviour hinders disconfirmation of the feared consequence.
A second loop illustrates how rituals can lead to further initial triggers/intrusions.
As demon-strated in the “white bears” research1, trying to suppress thoughts and
intrusions often simply causes them to return even more strongly. The same
applies to other ways of trying to neut-ralise or control internal intrusions.
Additionally rituals such as repeated checking or cleaning can set up and
strengthen links between situations and triggers/ intrusions. Gradually this can
cause the network of situations that trigger intrusions to widen and involve more
and more of one’s life.

understanding the flow chart: This model of OCD is quite complicated

and only parts will be really important in any individual case. It is usually
necessary to go over the chart care-fully with a therapist. Progressively one can
build up an understanding of what aspects are personally relevant for making
progress. It is then crucial to move increasingly from a simple intellectual
understanding of the model to a real change in gut feeling about intrusive
thoughts. Moving from rational understanding to gut feeling takes time and
involves detective work. This detective work is likely to include three components.
One component is learning more about obsessive compulsive disorder in general.
Research2 has shown that nearly 90% of normal people report that they get
unpleasant, unwanted thoughts and impulses. A more recent survey 3 found that
when asked to monitor spontan-eous, repetitive, intrusive thoughts, subjects
reported an average of 7 or 8 such intrusions
per day. The most common emotion accompanying these intrusions was a feeling
of fear. Fascinatingly it is not the frequency of intrusions that is associated with
how upsetting people feel they are2. More important is how easily the person feels
it is to dismiss the thoughts from their mind. To qualify as formal obsessive
compulsive disorder, the obsessions or compulsions must be causing marked
distress, be time consuming, or be significantly interfering with a person’s life 4.
OCD affects about 2% of the population. It is the fourth most common mental
disorder5 and is nearly as common as asthma or diabetes.
The therapeutic detective work’s second component involves looking back at the
behaviour of one’s own symptoms to understand better how they fit into the flow
chart. The third compon-ent is usually the most important. It consists of
developing behavioural experiments to test out the chart. Do intrusive thoughts
warn of genuine dangers, or are they just common, transient experiences that can
be allowed to float into the mind and simply float out again? This pract-ical testing
is typically the most powerful way to change gut feelings about intrusions, and
therefore make valuable, long term therapeutic gains.

1. Wegner DM White bears and other unwanted thoughts New York: Guilford Press, 1994
2. Salkovskis PM, et al Abnormal and normal obsessions – a replication Behav Res Ther 1984;22:549-52
3. Brewin CR, et al Intrusive thoughts and intrusive memories in a nonclinical sample Cognition & emotion
1996;10:107-12
4. APA Diagnostic & statistical manual of mental disorders (4th ed.) Washington: American Psychiatric Press,
1994
5. Nymberg JH, et al OCD: a concealed diagnosis American Fam Physician 1994;49:1129-37 & 1142-4