ocd case study psychology

Module 5: Obsessive Compulsive Disorder and Stressor Related Disorders

Case studies: ocd and ptsd, learning objectives.

• Identify OCD and PTSD in case studies

Case Study: Mauricio

Case Study: Cho

Possible treatment considerations for Cho may include CBT or eye movement desensitization and reprocessing (EMDR). This could also be coupled with pharmaceutical treatment, such as anti-anxiety medication or anti-depressants to help alleviate symptoms. Cho will need a trauma therapist who is experienced in working with adolescents. Other treatment that may be helpful is starting family therapy as well to ensure everyone is learning to cope with the trauma and work together through the painful experience.

Link to Learning

To read more about the ongoing issues of PTSD in violent-prone communities, read this article about a mother and her seven-year-old with PTSD .

Think It Over

If you were a licensed counselor working in a community that experienced a high rate of violent crimes, how might you treat the patients that sought therapeutic help? What might be some of the challenges in assisting them?

• Case Studies. Authored by : Christina Hicks for Lumen Learning. Provided by : Lumen Learning. License : Public Domain: No Known Copyright
• Desk top. Located at : https://www.pickpik.com/desk-top-desk-notebook-keyboard-desktop-shallow-116155 . License : Public Domain: No Known Copyright
• Lightning strike. Authored by : John Fowler. Located at : https://www.flickr.com/photos/snowpeak/3761397491 . License : CC BY: Attribution

Obsessive Compulsive Disorder (OCD)

Obsessions are unwanted thoughts and images that pop into your mind which you find unacceptable, or which make you feel anxious. Compulsions are things that you do in response to your obsessions, often to stop harm from occurring, or just to make you feel better. People who experience obsessions and compulsions to a level that interferes significantly with their life are said to have obsessive compulsive disorder (OCD), and it is thought that between 1 and 2 people out of every 100 experience OCD every year [1] . Fortunately, there are some effective psychological treatments for OCD including Cognitive Behavioral Therapy (CBT) and Exposure and Response Prevention (ERP) .

What is OCD?

Obsessive compulsive disorder is often misunderstood. You might have heard people refer to themselves as ‘being OCD’ if they like things to be arranged ‘just so’, but in fact obsessive compulsive disorder is about suffering from ‘obsessions’ and ‘compulsions’. These words aren’t often used in everyday language, so it can be worth knowing how psychologists understand these terms.

Obsessions are unwanted thoughts, images, urges, or doubts that you find unacceptable, and which make you feel anxious. They are sometimes called ‘intrusive’ thoughts because they pop into your mind – or ‘intrude’ – when you are going about your life. People with OCD find that these thoughts are repeated and persistent, and often scary, unacceptable, or disgusting. Commonly experienced thoughts include:

If you have OCD you might have a lot of thoughts like these, but they will often be focused around a particular theme. Some of the most common obsessive themes are:

Compulsions

Compulsions are things that you do, or ways that you react, in response to your obsessions. Your compulsions might be actions, rituals or behaviors that other people can observe, or they might be things that you do secretly in your mind. People with OCD normally use their compulsions either to prevent some harm that they fear might occur, or to relieve a feeling of anxiety or distress. Many people with OCD realize that their compulsions are not rational but feel compelled to carry them out anyway. Examples of common compulsions include:

• Repeated checking. For example, checking that you did not harm yourself or someone else, checking that something terrible did not happen, verifying that you did not make a mistake, checking that you turned the oven off, checking that you locked the door.
• Washing and cleaning. For example, washing your hands until they feel clean, cleaning your house or particular items obsessively, excessive washing or grooming.
• Mental compulsions. For example, praying to prevent harm, ‘canceling’ a bad thought or word with a good one, counting and ending on a ‘right’ or ‘good’ number.
• Repeating. For example, repeating activities, body movements, or mental events.

What is it like to have OCD?

More than many other psychological conditions, the way OCD looks to an outsider can vary a great deal. Monica’s story is just one example of how OCD can affect your life.

Monica’s fear that she would harm her baby

Shortly after my first baby was born, I started worrying that I would harm her. I would have unwanted thoughts and images of smothering or suffocating my baby, and whenever I was in a high place, I would have unwanted thoughts like “what if I threw her off?”. It was horrifying – I thought this meant I was a terrible mother and couldn’t be trusted to be alone with my baby. I tried to push these thoughts away as much as I could. To keep the baby safe, I insisted that my husband be responsible for most of her care. If I couldn’t avoid looking after her, I would pray in my mind the whole time that nothing bad would happen. I didn’t tell anyone about these thoughts in case she was taken away from me.

Do I have OCD?

A diagnosis of OCD should only be made by a mental health professional. However, answering the screening questions below can give you an idea of whether you might find it helpful have a professional assessment.

If you ticked the rightmost box to lots of these questions it is an indication that you could be suffering from OCD.

What causes OCD?

There is no single cause for OCD. You are more likely to experience OCD if you have:

• Assumptions and beliefs that make you more likely to develop OCD.
• Early experiences which made you vulnerable to OCD, or made you feel particularly responsible for preventing bad things from happening.
• Critical incidents such as stresses or challenges which kick-start the OCD.

There may be genes which make you likely to develop emotional problems in general, but no specific genes have been found which make you likely to develop OCD [2] .

What keeps OCD going?

Research studies have shown that Cognitive Behavioral Therapy (CBT) is one of the most effective psychological therapies for OCD. CBT therapists work a bit like firefighters: while the fire is burning they’re not so interested in what caused it, but are more focused on what is keeping it going, and what they can do to put it out. This is because if they can work out what keeps a problem going, they can treat the problem by ‘removing the fuel’ and interrupting this maintainance cycle.

The important insight of CBT is that the way we feel depends on how we have interpreted what is happening to us. With OCD, this means that the way you interpret your obsessions will affect how you feel, and how you respond to them. Having strong beliefs about being responsible for preventing harm can make you more likely to interpret obsessions in problematic ways. Once you have interpreted particular thoughts as threatening, you are likely to do certain things to keep yourself or others safe [3] . These include:

Treatments for OCD

Psychological treatments for ocd.

The most effective psychological treatments for OCD are cognitive behavioral therapy (CBT) and exposure and response prevention (ERP). Specialist guidelines recommend that if you have OCD where the degree of impairment is mild, you should be offered a minimum of 10 hours with a therapist, or longer if the OCD is more severe [4] .

CBT is a popular form of talking therapy. CBT therapists understand that what we think and do affects the way we feel. Unlike some other therapies, it is often quite structured. After talking things through so that they can understand your problem, you can expect your therapist to set goals with you so that you both know what you are working towards. At the start of most sessions you will set an agenda together so that you have agreed what that session will concentrate on. OCD specialists have made some recommendations about what high quality CBT for OCD should look like [5] . The most important ‘ingredients’ include:

• Focusing on the OCD problem for most of the time in most of the sessions.
• Working towards collaboratively developed goals which are specific, achievable, and described in terms of what you will do.
• Explaining how your OCD works and what keeps it going (psychologists call this a case conceptualization or case formulation).
• Therapist-aided exposure where you have an opportunity to test some of your beliefs and to face your fears.
• Between-session tasks likely to consist of monitoring, exposure, and behavioral experiments .
• Consistent encouragement to resist your rituals or compulsions.

Medical treatments for OCD

The UK National Institute for Health and Care Excellence (NICE) recommends that medications called selective serotonin reuptake inhibitors (SSRIs) can be effective in treating adults with OCD [3] .

• Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry , 62(6), 617-627.
• Mattheisen, M., Samuels, J. F., Wang, Y., Greenberg, B. D., Fyer, A. J., McCracken, J. T., … & Riddle, M. A. (2015). Genome-wide association study in obsessive-compulsive disorder: results from the OCGAS. Molecular Psychiatry , 20(3), 337.
• Salkovskis, P. M., Forrester, E., & Richards, C. (1998). Cognitive–behavioural approach to understanding obsessional thinking. The British Journal of Psychiatry , 173(S35), 53-63.
• National Institute for Health and Care Excellence (2005). Obsessive compulsive disorder and body dysmorphic disorder: treatment. Retrieved from: https://www.nice.org.uk/guidance/cg31/resources/obsessivecompulsive-disorder-and-body-dysmorphic-disorder-treatment-pdf-975381519301
• Darnley, S., Forrester, E., Heyman, I., Stobie, B., Salkovskis, P, Veale, D. (2019). CBT Checklist for OCD. Retrieved from: https://www.ocdaction.org.uk/support-info/have-i-had-cbt-my-ocd

About this article

This article was written by Dr Matthew Whalley and Dr Hardeep Kaur, both clinical psychologists. It was last reviewed on 2021/12/08.

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CLINICAL CASE STUDY article

A clinical case study of the use of ecological momentary assessment in obsessive compulsive disorder.

• Brain, Behaviour and Mental Health Research Group, School of Psychology and Speech Pathology, Curtin University, Perth, WA, Australia

Accurate assessment of obsessions and compulsions is a crucial step in treatment planning for Obsessive-Compulsive Disorder (OCD). In this clinical case study, we sought to determine if the use of Ecological Momentary Assessment (EMA) could provide additional symptom information beyond that captured during standard assessment of OCD. We studied three adults diagnosed with OCD and compared the number and types of obsessions and compulsions captured using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) compared to EMA. Following completion of the Y-BOCS interview, participants then recorded their OCD symptoms into a digital voice recorder across a 12-h period in reply to randomly sent mobile phone SMS prompts. The EMA approach yielded a lower number of symptoms of obsessions and compulsions than the Y-BOCS but produced additional types of obsessions and compulsions not previously identified by the Y-BOCS. We conclude that the EMA-OCD procedure may represent a worthy addition to the suite of assessment tools used when working with clients who have OCD. Further research with larger samples is required to strengthen this conclusion.

Introduction

Obsessive-Compulsive Disorder (OCD) is a disabling anxiety disorder characterized by upsetting, unwanted cognitions (obsessions) and intense and time consuming recurrent compulsions ( American Psychiatric Association, 2000 ). The idiosyncratic nature of the symptoms of OCD ( Whittal et al., 2010 ) represents a challenge to completing accurate and comprehensive assessments, which if not achieved, can have a deleterious effect on the provision of effective treatment for the disorder ( Kim et al., 1989 ; Taylor, 1995 ; Steketee and Barlow, 2002 ; Deacon and Abramowitz, 2005 ).

Accurately assessing the full range of symptoms of OCD requires reliable and psychometrically sound diagnostic instruments and measures ( Taylor, 1995 , 1998 ; Rees, 2009 ) alongside the standard clinical interview. Although the most commonly used psychometric instrument for assessing OCD, the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) ( Goodman et al., 1989a , b ), has acceptable reliability and convergent validity, it has been criticized by Taylor (1995) for weak discriminant validity. Taylor also highlighted that it remains susceptible to administration variance, relies on client memory recall, and is time consuming to administer. As with all measures completed retrospectively, selective memory biases affect the type of information reported by clients about their symptoms ( Clark, 1988 ; Stone and Shiffman, 2002 ; Stone et al., 2004 ). Glass and Arnkoff (1997 , p. 912) have summarized several disadvantages of structured inventories; first, they contain prototypical statements which may fail to capture the idiosyncratic nature of the client's actual thoughts; second, they can be affected by post-hoc reappraisals of what clients feel, as the data is subject to memory recall biases; and finally they may fail to adequately capture the client's internal dialog due to the limitations of the best fit question structure.

Discrepancies have been reported between data collected in the client's natural environment ( in situ ) and those based on the client's later recall ( de Beurs et al., 1992 ; Marks and Hemsley, 1999 ; Stone et al., 2004) . Such discrepancies may be further affected by factors such as the complexity and diversity of obsessions and compulsions, not to mention the ego-dystonic nature of many OCD clients' obsessional thoughts. It seems likely that clients with distressing ego-dystonic obsessions, for example, those involving sexual, aggressive, and/or religious themes may experience a heightened level of discomfort in reporting their obsessions in a face to face assessment with a clinician, thus reducing their willingness to accurately report ( Taylor, 1995 ; Newth and Rachman, 2001 ; Grant et al., 2006 ; Rees, 2009 ). This may contribute to an underreporting of these obsessions, and hence an inaccurate understanding and a restriction of the clinician's ability to adequately treat the client ( Grant et al., 2006 ; Rachman, 2007 ).

Exposure and response prevention, cognitive therapy, and pharmacological interventions have been shown to be effective in the treatment of OCD ( Abramowitz, 1997 , 2001 ; Foa and Franklin, 2001 ; Steketee and Barlow, 2002 ; Fisher and Wells, 2008 ; Chosak et al., 2009 ). Self-monitoring is a useful therapeutic technique that provides essential information to assist in the development of exposure hierarchies and behavioral experiments used in cognitive therapy ( Tolin, 2009 ). Clients typically observe and record their experiences of target behaviors, including triggers, environmental events surrounding those experiences, and their response to those experiences ( Cormier and Nurius, 2003 ). Such self-monitoring can be used to both assist assessment and/or as an intervention. Cormier and Nurius (2003) explained that the mere act of observing and monitoring one's own behavior and experiences can produce change. As people observe themselves and collect data about what they observe, their behavior may be influenced.

A form of self-monitoring and alternative to the typical clinic-based assessment of OCD is the use of sampling from the client's real-world experiences, a procedure known as Ecological Momentary Assessment (EMA) ( Schwartz and Stone, 1998 ; Stone and Shiffman, 1994 , 2002 ). EMA does not rely on measurements using memory recall within the clinical setting, but rather allows for collection of information about the client's experiences in their natural setting, potentially improving the assessment's ecological validity ( Stone and Shiffman, 2002 ). In situ sampling techniques have been successfully used in psychology, psychiatry, and occupational therapy (for a more detailed account see research by Morgan et al., 1990 ; de Beurs et al., 1992 ; Kamarack et al., 1998 ; Litt et al., 1998 ; Kimhy et al., 2006 ; Gloster et al., 2008 ; Putnam and McSweeney, 2008 ; Trull et al., 2008 ). Generally it is agreed that EMA offers broader assessment within the client's natural environment, as it includes random time sampling of the client's experience, recording of events associated with the client's experience, and self-reports regarding the client's behaviors and physiological experiences ( Stone and Shiffman, 2002 ). Because this assessment method accesses information about the client's situation, the difficulties of memory distortions like recall bias are reduced ( Schwartz and Stone, 1998 ; Stone and Shiffman, 2002 ).

Given that accurate assessment of obsessions and compulsions is a critical aspect of treatment planning and that reliance on self-report and clinician interview has some known limitations, the purpose of this study was to investigate the utility of EMA as a potential adjunct to the conventional assessment of OCD. Specifically, we sought to compare the amount and type of information regarding obsessions and compulsions collected via EMA vs. standard assessment using the gold-standard symptom interview for OCD. As this is a pilot clinical case study, we offer the following tentative hypothesis: (1) EMA will yield additional types of obsessions and compulsions not captured by the Y-BOCS.

Participants and Setting

Participants were recruited through clients presenting to the OCD clinic at Curtin University. They were assessed using the Structured Clinical Interview for DSM-IV (SCID-IV) ( First et al., 1997 ). Inclusion in the study was based on receiving a primary diagnosis of OCD, and a Y-BOCS ( Goodman et al., 1989a , b ) score of more than 16, placing their OCD symptom severity within the clinical range ( Steketee and Barlow, 2002 ). Participants were excluded if they presented with current suicidal ideation, psychotic disorders, apparent organic causes of anxiety, were severely depressed, or if they had an intellectual disability. One potential participant was excluded post evaluation despite meeting the inclusion criteria, as she did not own a mobile phone, and reported having “blackouts” throughout the day. The three participants all had OCD symptoms in the “severe” range according to the YBOCS. In order to ensure that participants remain anonymous, pseudonyms have been used.

Participant A

Mary was a 28-year-old female who lived with her husband and small dog. She reported that for approximately 1 year she had been experiencing distressing intrusive thoughts in relation to harming her loved ones, herself, or her dog; for example, by stabbing, electrocution, or breaking the dog's neck. Mary said that she also had reoccurring thoughts and images that her husband or other family members might die. She reported engaging in some rituals, for example straightening pillows and rearranging tea-towels; but mostly reported using “safety nets” in response to her unwanted cognitions; for example ensuring that she was not alone (to prevent self-harm); avoidance and removal of feared object; extensive reassurance seeking from family members. According to the Y-BOCS measure, Mary scored a subtotal of 14 for Obsessions and a subtotal of 18 for Compulsions, giving an overall total of 32, classifying her symptoms as “severe” ( Steketee and Barlow, 2002 ).

Mary reported that her OCD first occurred after her grandmother passed away about 6 years ago. She explained they had a very close relationship, she said she found it “unbearably distressing” to visit her while she was dying. Mary reported that on one occasion whilst in a coma, her grandmother sat up and gasped, which she found extremely frightening and still remembers it in vivid detail. She reported that she experienced thoughts that her grandmother was in pain and was going “into the unknown, to a scary place.” Mary reported feeling afraid of death and that if someone “even closer” to her died she “would not be able to cope” and that she would “lose control completely.” She stated that her biggest fear was that her husband, mother or father might die. Mary reported that she has been on various anti-depressants for about 10 years. She stated that recently her psychiatrist prescribed Solian (an antipsychotic) which she tried, and found was very effective at blocking out the intrusive thoughts. However, she ceased taking the medication due to nausea.

Participant B

John was a 5-year-old man who lived with his wife and adult son. He reported a long history of distressing intrusive thoughts, and compulsive behaviors. They are summarized in three ways. First, those that relate to religious obsessions, specifically the occult and satanic experiences/fear of being “possessed.” He reported responding to these unwanted cognitions by either washing his hands to cleanse himself; using more than six pieces of toilet paper to wipe after defecating to prevent the devil entering him via his anus; or looking for the number “555,” which represents “God. This is good.” John reported that failing to act in these ways would risk causing harm to his wife and son. Second, those that relate to checking compulsions, specifically when driving, and also checking that doors are locked—which he reported doing 4–12 times per night. He reported that if he thought he heard a “bump” when driving he would have to turn back to check he had not run anyone over, or would seek reassurance from his son or wife if they were passengers in the car with him. He stated that he feared that harm would come to his wife and son if he didn't perform these checks. Third, John said that he arranged shoes so that they were “lined up” and that the clothes in the cupboard were in the “right order.” He also reported the need to compulsively clean his son's bedroom, and that he wouldn't feel “right” until he had done so. According to the Y-BOCS measure, John scored a subtotal of 13 for Obsessions and a subtotal of 15 for Compulsions, giving an overall total of 28, classifying his symptoms as “severe” ( Steketee and Barlow, 2002 ).

John reported that his symptoms have been present for at least the last 29 years. He reported that his OCD first occurred after he had a “break-down” and tried to commit suicide by stabbing himself in the stomach before he turned 25 years of age. In the years leading up to this, John reported two poignant experiences which appear relevant to the development of his symptoms; he reported being involved in the euthanizing of two dogs whilst working as a Ranger's assistant; and that when he was young, he and his girlfriend at the time had a pregnancy termination. John reported feeling that these were “blasphemous” acts, and posed the question “Is God punishing me?” John reported that he had been on several different anti-depressants for about 19 years, with varying degrees of success and side-effects. He reported that he had seen a psychiatrist every 6 weeks for “many years” and finds being able to talk helpful.

Participant C

Paul was a 35-year-old man, who reported distressing intrusive thoughts and images in relation to harm coming to others as a consequence of him not checking that he had done what he is “supposed to do.” For example, he was concerned that someone at work would be harmed if he forgot to adequately cover shifts on the roster (something he is responsible for); or when a client of the service he coordinates was recently given a stereo, Paul reported that he feared that harm would come to the client if he didn't correctly check it to see if it was faulty, something he felt responsible to do.

Paul reported that only his partner knew of his difficulties. He stated that he did not allow his anxiety to interfere too much with his occupational functioning; however he did report that the main reason he does not practice in his profession is because of his OCD. According to the Y-BOCS measure, Paul scored a subtotal of 12 for Obsessions and a subtotal of 13 for Compulsions, giving an overall total of 25, classifying his symptoms as “severe” ( Steketee and Barlow, 2002 ).

Paul reported that his intrusive thoughts have “always been there.” He explained that one of the first clear memories he has of them, was when he was seven years old and he saw the film the “The Omen.” He reported remembering checking his head for the numbers “666.” Additionally, he reported remembering that he was concerned for his mother's safety. He reported that he had never taken medication for his OCD. He stated that he saw two therapists when he lived in the UK at an OCD center in London approximately 18 months ago. Paul said that he did not gain much from the first therapist, but believes that second therapist assisted him to look at his cognitions as “just thoughts.”

Materials and Methods

All screening of participants, interviewing and assessment, as well as administration of the study, was conducted by the first author, who was a provisionally registered psychologist undergoing postgraduate training at the time of the research, and was supervised by the second author, an experienced OCD clinician and academic. Potential participants were recruited from the Curtin OCD clinic. They were screened via telephone to ascertain their suitability for the study. A face-to-face assessment session using the Structured Clinical Interview for DSM-IV (SCID-IV; First et al., 1997 ) was conducted to determine a primary OCD diagnosis, followed by the administration of the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) interview and checklist ( Goodman et al., 1989b ) to identify the participants' obsessions and compulsions and their symptom severity. The Y-BOCS is the most widely used scale for OCD symptoms assessment and is considered by researchers to be the “gold standard” measure for symptom severity ( Deacon and Abramowitz, 2005 ; Himle and Franklin, 2009 ). It consists of two parts; a checklist of prelisted types of obsessions, usually endorsed by the clinician based on disclosures made by the client; and the severity scale which requires the client to rate the severity of their experience by answering the questions based on their recall. Goodman et al. (1989) note that the Y-BOCS has shown adequate interrater agreement, internal consistency, and validity.

Suitable participants then attended a second session where they signed consent forms and were given instructions about the study procedure. During the data collection using the Ecological Momentary Assessment data (EMA-OCD), participants used an Olympus WS-110 digital voice recorder to record their experiences throughout a 12 h period. Participants used their existing mobile phones to receive prompts via the mobile phone Short Message Service (SMS) to record their responses to the research questions. All three participants were then provided with an envelope containing the Olympus WS-100 digital voice recorder, a spare battery, and the participant prompt questions (see Table 1 ).

Table 1. Prompt questions .

Participants were asked to turn their mobile phones on during the data collection day by 10 am, ready to receive their SMS prompts. The researcher manually sent SMS prompts to the participants at random intervals; at least every 2 h (across 1 day, from 10 am to 10 pm), for a minimum of 10 data entries in keeping with research using EMA procedures (see, Stone and Shiffman, 2002 ); asking them to complete their responses to all four questions as details on the EMA-OCD Participant Questions Sheet. Participants were instructed not to respond to the SMS prompts if driving, and were asked to respond as quickly as possible to the prompts. Data was then downloaded from the voice recorder to the researcher's computer, and transcribed. During this process all identifying details were removed. During the debrief session open-ended questions were used to gather as much information as possible regarding the participant's experiences of the study, and suggestions for improvements. During the data collection day the researcher completed a journal to record his observations and reflections related to the use of the EMA. At the completion of the EMD-OCD data collection, each of the participants was provided with a debrief session (Mary by phone, and John and Paul, face to face). The debrief session focused on their experiences of the research and use of the digital voice recorder; and provided the opportunity for them to discuss anything else that arose they wished to tell the researcher. As stated above, the data was downloaded and transcribed by the first author. The Y-BOCS obsession and compulsion categories were used as a framework to compare the data generated from the EMA-OCD procedure. After the complete de-identified data set was tabled, it was provided to a second person who was an expert in OCD for verification of categories. In the case of any discrepancies agreement was reached via consensus.

Number of reported symptoms

Table 2 provides a summary of the frequency and type of symptoms recorded during both the face-to-face session, which will be referred to as the Y-BOCS data and the EMA-OCD phase for the study, which will be referred to as the EMA–OCD data. As can be seen when comparing the data contained in the two columns, there are variations between the Y-BOCS data and the EMA-OCD data. All three participants reported more categories of both obsessions and compulsions in the Y-BOCS data, compared to that reported in the EMA-OCD data.

Table 2. Summary by participant of Y-BOCS data and EMA-OCD data .

Mary reported experiencing five categories of Y-BOCS Obsessions and six categories of Compulsions in the Y-BOCS data. In the EMA-OCD data she reported experiencing two categories of Y-BOCS Obsessions, and three categories of Y-BOCS Compulsions. John reported experiencing four categories of Y-BOCS Obsessions and five categories of Compulsions in the Y-BOCS data. In the EMA-OCD data he reported experiencing two categories of Y-BOCS Obsessions, and five categories of Y-BOCS Compulsions. Paul reported experiencing four categories of Y-BOCS Obsessions and two categories of Compulsions in the Y-BOCS data. In the EMA-OCD data he reported experiencing one category of Y-BOCS Obsessions, and two categories of Compulsions.

Comparison of content of symptoms

Both Mary and Paul reported previously unidentified Obsessions or intrusive thoughts in the EMA-OCD data, compared to the Y-BOCS data; and all three participants reported previously unidentified compulsions/rituals/responses in the EMA-OCD data. As can be seen in Table 2 , Mary reported two intrusive thoughts in the EMA-OCD data that were not recorded in the Y-BOCS data. Additionally, she reported a previously unreported obsession under the obsession category Obsession with need for Symmetry or Exactness , not reported in the Y-BOCS data. Mary also reported variations on her compulsive behaviors and the presence of thought suppression not identified during the administration of the Y-BOCS. The EMA-OCD data indicated that John substituted one of his compulsions for an alternative anxiety reducing act, which was not recorded in the Y-BOCS data and suggests the identification of a previously unreported compulsion. Additionally, the EMA-OCD data indicated that John engaged in thought suppression to neutralize his intrusive thoughts. Likewise, John's reported compulsive behaviors also varied between data sets. In the EMA-OCD data he reported three previously unreported compulsive behaviors, and like Mary also the presence of thought suppression. In addition to the above, the EMA-OCD data indicated that John substituted one of his rituals for another, when he touched a crucifix instead of performing his usual hand washing ritual to cleanse him-self of the potential satanic possession. This was not something reported in the Y-BOCS data.

This study investigated the utility of EMA as an adjunct assessment approach for OCD. Each of our study hypotheses was supported. As predicted the EMA procedure resulted in the identification of additional types of obsessions and compulsions not captured by the Y-BOCS interview. The finding that the EMA procedure identifies obsession and compulsion symptoms not captured by the Y-BOCS suggests that further studies in this area are warranted. As a pilot case study we cannot generalize from these initial findings but our results indicate that a larger study replicating the procedure used here, is justified. Importantly, the three participants in our study were representative of quite typical OCD clients in that they had severe levels of symptoms and had OCD for a number of years. The EMA procedure we used was found to be satisfactory to all three participants. Feedback from the participants at the de-briefing session included suggestions that this process would be helpful for therapy because it would provide the therapist and client with rich and current material regarding their symptom patterns. From a clinician's point of view, collecting the EMA data is not onerous because the entries are simply short answers collected on 12 occasions and thus is not a time-consuming exercise.

The EMA procedure as used in this study could provide clinicians with a new method by which to gain a current and accurate snap-shot of clients symptoms as they occur in real-time. This information could augment information gained from standard pencil and paper measures but also provide an “active” process which may help to engage clients in the therapeutic process. It seems likely that using a procedure like EMA with OCD clients will assist in understanding their OCD experiences, and thus assist in generating valuable information, supporting accurate assessment, client conceptualization, and ultimately treatment.

Despite these valuable findings, there are limitations of this study. As a pilot study and exploratory in nature, it is only possible to draw limited interpretations from the data provided. However, the preliminary findings of this study support the benefit of conducting further research into this procedure, where it may be possible to draw more empirically valid findings from a larger and more statistically powerful sample. Second, due to the lack of availability of date stamping, participants were asked to record the time they made each recording. Unfortunately this was not routinely provided by all participants, and hence creates an unanswerable question regarding the accuracy of the data recorded. As Stone and Shiffman (2002) discuss, a potential problem relates to participants recording their data based on their recall of what was occurring at the time of the SMS prompt, rather than immediately. Hence introducing possible memory bias, and undermining the premise of the study. Although this is certainly an unwanted variable, based on the EMA-OCD data provided it seems that except for Mary, both John and Paul responded promptly to the SMS messages, or recorded the time if they didn't. Mary on the other hand, reported during the debrief session that she was unable to record the time for the initial targets, but did so for subsequent SMS prompts. It was not possible to ascertain from her data the delay in time between the first SMS prompts and her recordings. In future applications of this procedure, it is recommended that the device used provides automatic date-stamping to address this limitation. Indeed, it may be possible to adapt the EMA methodology for use with smart phones via a dedicated OCD application.

Concluding Remarks

The findings from this study of three patients with severe OCD suggest that the use of EMA provides important additional information regarding obsessions and compulsions and may thus be a useful adjunct to the clinical assessment of OCD.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We thank the three participants for taking part in this study.

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Keywords: obsessive-compulsive disorder (OCD), ecological momentary assessment, ecological momentary assessment data, anxiety disorders, assessment

Citation: Tilley PJM and Rees CS (2014) A clinical case study of the use of ecological momentary assessment in obsessive compulsive disorder. Front. Psychol . 5 :339. doi: 10.3389/fpsyg.2014.00339

Received: 10 March 2014; Accepted: 01 April 2014; Published online: 17 April 2014.

Reviewed by:

Copyright © 2014 Tilley and Rees. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Clare S. Rees, Brain, Behaviour and Mental Health Research Group, School of Psychology and Speech Pathology, Curtin University, Perth, WA, Australia e-mail: [email protected]

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Case Report: Obsessive compulsive disorder in posterior cerebellar infarction - illustrating clinical and functional connectivity modulation using MRI-informed transcranial magnetic stimulation

Urvakhsh Meherwan Mehta Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Darshan Shadakshari Roles: Data Curation, Investigation, Resources, Writing – Review & Editing Pulaparambil Vani Roles: Data Curation, Investigation, Methodology, Supervision, Writing – Review & Editing Shalini S Naik Roles: Methodology, Project Administration, Writing – Review & Editing V Kiran Raj Roles: Data Curation, Formal Analysis, Visualization, Writing – Review & Editing Reddy Rani Vangimalla Roles: Data Curation, Formal Analysis, Visualization, Writing – Review & Editing YC Janardhan Reddy Roles: Supervision, Writing – Review & Editing Jaya Sreevalsan-Nair Roles: Formal Analysis, Investigation, Visualization, Writing – Review & Editing Rose Dawn Bharath Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Supervision, Visualization, Writing – Review & Editing

This article is included in the Wellcome Trust/DBT India Alliance gateway.

Obsessive Compulsive Disorder, Cerebellar cognitive affective syndrome, Neuromodulation, Functional brain connectivity, Cerebellar infarct, Theta burst stimulation

Revised Amendments from Version 1

The new version provides more clinical details about the patient, in response to the review comments raised. These include details and justifications for past treatment, iTBS treatment details, rationale for performing an MRI scan and follow-up information beyond the earlier reported period of three months.

See the authors' detailed response to the review by Shubhmohan Singh See the authors' detailed response to the review by Peter Enticott

Introduction

Cortico-striato-thalamocortical circuitry dysfunction is central to an integrated neuroscience formulation of obsessive-compulsive disorder (OCD) 1 , 2 . However, more recent large-scale brain connectivity analyses implicate the role of the cerebello-thalamocortical networks also 3 . Here, we report a case of OCD secondary to a cerebellar lesion. We test the mediating role of the cerebellum in the manifestation of OCD by manipulating the frontal-cerebellar network using MRI-informed transcranial magnetic stimulation (TMS).

Case report

A 21-year-old male, an undergraduate student from rural south India, presented to our emergency with suicidal thoughts. History revealed three years of academic decline, pathological slowness in routine activities (e.g., bathing, eating, dressing up, and using the toilet), repetitive ‘just-right’ behaviors (e.g., wiping his mouth after eating, clearing his throat, pulling down his shirt, mixing his food in the plate and walking back and forth until ‘feeling satisfied’). As a result, he spent up to three hours completing a meal or his toilet routines. Before presentation to us, he had received trials with two separate courses of electroconvulsive therapy (ECT) – six bitemporal ECTs at first, followed by nine bifrontal) spaced about two months apart. ECT was prescribed because of a further deterioration in his condition over the prior 18-months, with reduced oral intake, weight loss, grossly diminished speech output, and passing urine in bed (as he would remain in bed secondary to his obsessive ambitendency, as disclosed later). His oral intake and speech output improved with both ECT treatments, only to gradually worsen over the next few weeks. Given the potential catatonic phenomena (withdrawn behaviour and mutism) in the background of ongoing academic decline, slowness and stereotypies, he was also treated with oral olanzapine 20mg for eight weeks and risperidone 6mg for six weeks with minimal change in his slowness and repetitive behaviors. He did not receive any antidepressant medications. Psychotherapy was also not considered given the limited feasibility due to the severe withdrawal and near mutism. We could not elicit any contributory clinical history of prodromal or mood symptoms from adolescence when we evaluated his past psychiatric and medical history. Two months after the last ECT treatment, he presented to our emergency services with suicidal thoughts. He was admitted, and mental status examination revealed aggressive (urges to harm himself by jumping in front of a moving vehicle or touching electric outlets) and sexual obsessions with mental compulsions and passing urine in bed (as he could not go to the toilet in time due to obsessive ambitendency). The Yale-Brown Obsessive-Compulsive Scale (YBOCS) severity score was 29 4 . He had good insight into obsessions, but not the ‘just right’ repetitive behaviors; it was, therefore, challenging to engage him in psychotherapy. We treated him with escitalopram 40mg and brief psychoeducation before being discharged. After three months, his obsessions had resolved, but pathological slowness, ‘just right’ phenomena, and passing urine in bed had worsened (YBOCS score 31).

We then obtained a plain and contrast brain MRI, to rule out an organic aetiology given the atypical nature of symptoms (apparent urinary incontinence) and the poor treatment response. The MRI revealed a wedge-shaped lesion in the right posterior cerebellum, suggestive of a chronic infarct in the posterior inferior cerebellar artery territory ( Figure-1A ). MR-angiogram revealed no focal narrowing of intracranial and extracranial vessels. Electroencephalography, cerebrospinal fluid analysis, autoimmune and vasculitis investigations were unremarkable. Echocardiogram was normal and the sickling test for sickle cell anemia was also negative. We specifically inquired about history of loss of consciousness, seizures or motor incoordination, but these were absent. His neurological examination with a detailed focus on cerebellar signs was unremarkable. The International Cooperative Ataxia Rating Scale (ICARS) score was zero. The Cerebellar Cognitive Affective Syndrome (CCAS) scale revealed >3 failed tests – in domains of attention, category switching, response inhibition, verbal fluency, and visuospatial drawing, suggestive of definite CCAS 5 .

Cerebellar lesion detection ( A & B ), its functional connectivity map ( C ) and MRI-guided transcranial magnetic stimulation delivery ( D ). Average blood oxygen level-dependent (BOLD) signal time-series were extracted from voxels within a binarized lesion-mask that overlapped with the right crus II ( 1A & 1B ). This was used as the model predictor in a general linear model to determine the brain regions that temporally correlated with the lesion-mask using FSL-FEAT 11 . The resultant seed-to-voxel connectivity map (z-thresholded at 4) was used to identify the best connectivity of the seed with voxels in the pre-supplementary motor area (pre-SMA; MNI x=3; y=13; z=58; 1C ). Six-hundred pulses were delivered as triplet bursts at theta frequency and 90% of the resting motor threshold (50 Hz; 2s on; 8s off) using a MagPro X100 (MagVenture, Denmark) device under MR-guided neuronavigation using the Brainsight stereotaxic system (Rogue Research, Montreal, Canada) with a figure-of-eight coil held with the handle in line with the sagittal plane, pointing toward the occiput to stimulate the pre-SMA site ( 1D ).

MRI-informed neuromodulation

Owing to inadequate treatment response and the possibility of OCD secondary to the cerebellar lesion, we discussed with the patient about MRI-informed repetitive transcranial magnetic stimulation (rTMS) and obtained his consent. The presence of a lesion involving a node (cerebellum) within the cerebello-thalamo-cortical circuit – a key pathway for error monitoring 6 and inhibitory control 7 – cognitive processes typically impacted in OCD prompted us to utilize a personalized-medicine approach to treatment. We acquired a resting-state functional-MRI echoplanar sequence (8m 20s; 250-volumes) in duplicate – before, and one-month after rTMS treatment on a 3-Tesla scanner (Skyra, Siemens), using a 20-channel coil with the following parameters: TR/TE/FA= 2000ms/30ms/78; voxel=3mm isotropic; FOV=192*192.

Image processing was performed using the FMRIB Software Library (FSL version-5.0.10) 8 . Figure 1 describes how we obtained a seed-to-voxel connectivity map to identify the best connectivity of the cerebellar lesion-seed with voxels in the pre-supplementary motor area (pre-SMA; MNI x=3; y=13; z=58) – a commonly used site for neuromodulation in OCD 9 . This area demonstrates connections with the non-motor (ventral dentate nucleus) parts of the posterolateral cerebellum 10 and contributes to error processing and inhibitory control along with the cerebellum 7 .

We augmented escitalopram with rTMS, administered as intermittent theta-burst stimulation (iTBS) to the pre-SMA coordinates ( Figure-1D ). Six-hundred pulses were delivered as triplet bursts at theta frequency and 90% of the resting motor threshold (50 Hz; 2s on; 8s off) using a MagPro X100 (MagVenture, Farum, Denmark) device under MR-guided neuronavigation using the BrainSight stereotaxic system (Rogue Research, Montreal, Canada) with a figure-of-eight (MagVenture MCF-B-70) coil held with the handle in line with the sagittal plane, pointing toward the occiput to stimulate the pre-SMA site. We hypothesized that iTBS 12 to the pre-SMA could adaptively engage the cerebellum lesion, with which it shares neuronal oscillation frequencies, and hence improve the disabling symptoms. He received 27 iTBS sessions, once daily over the next month. Following ten sessions, he began to show a reduction in his repetitive behaviors, and by the 15 th session, he acknowledged that his behaviors were irrational. The YBOCS severity score had reduced to 24 (~22.5% improvement), which remained the same, even at the end of 27 sessions of iTBS treatment. There was no change in the CCAS and ICARS scores. The clinical benefits remained unchanged until three months of follow-up. Subsequently, we observed a gradual reversal to pre-TMS symptom severity. Maintenance TMS was suggested but was not feasible due to logistic reasons and therefore he was initiated on oral fluoxetine that was gradually increased to 80mg/day, with which we observed minimal change in symptoms over the next four months.

Post-neuromodulation functional connectivity visualization

The pre- and post-rTMS scans 13 were parcellated into 48-cortical, 15-subcortical, and 28-cerebellar regions as per the Harvard-Oxford 14 and the Cerebellum MNI-FLIRT atlases 15 . Average BOLD-signal time-series from each of these nodes, obtained after processing within FSL version-5.0.10, were then concatenated to obtain a Pearson’s correlation matrix between 91 nodes, separately for the pre- and post-TMS studies.

We analyzed the two 91 × 91 matrices using the Rank-two ellipse (R2E) seriation technique for node clustering 16 ( Figure 2 ). This technique reorders the nodes by moving the ones with a higher correlation closer to the diagonal. Thus, blocks along the diagonal of the matrix visualization show possible functional coactivating clusters.

Rank-two ellipse seriation-based visualization of correlation matrix before ( A ) and after ( B ) rTMS treatment. The dotted-black boxes denote the cerebellar network and other connected networks, where the green boxes show the inter-network overlap. Thus, we see that the overlapped region in ( 2A ) has now transitioned to three different overlapped areas in ( 2B ), which shows the increase in the overlap between modular networks after treatment. Cerebellar nodes are denoted in black, cortical nodes in blue and subcortical nodes in green. The lesion node (right crus II) and the region of neuro-stimulation are given in red; R2E= Rank-two ellipse.

We observed (a) extended connectivity of the cerebellar network after iTBS treatment as evidenced through its diminished modularity – the larger cerebellar cluster/block had an increased overlap with both anterior and posterior brain networks as observed along the diagonal in ( Figure 2B ), and (b) formation of better-defined sub-clusters within the larger cerebellar cluster indicating improved within-network modularity of distinct functional cerebellar networks [e.g., vestibular (lobules IX and X) and cognitive-limbic (crus I/II and vermis)].

Conclusions

We illustrate a case of OCD possibly secondary to a posterior cerebellar infarct, supporting the role of the cerebellum in the pathophysiology of OCD 3 . That OCD was perhaps secondary to the posterior cerebellar lesion is supported by several lines of evidence. Firstly, there seemed to be a possible temporal correlation between the duration of OCD and the chronic nature of the cerebellar lesion. Despite the challenges in inferring a precise temporal relationship based on clinical history, the signal changes with free diffusion and atrophy indicated that the infarct was indeed chronic, supporting the symptom onset at about three years before presentation. Previous studies have indeed reported OCD in posterior cerebellar lesions 17 – 19 . Secondly, the clinical phenotype was somewhat atypical, characterized by severe ambitendency, precipitating urinary incontinence, and poor insight into compulsions along with comorbid CCAS. Thirdly, our patient was resistant to an anti-obsessional medication but improved partially with neuromodulation of the related circuit. The MRI-informed iTBS engaged the lesion-area by targeting its more superficial connections in the frontal lobe. The changes in clinical observations paralleled the changes in cerebellar functional connectivity – enhanced within-cerebellum modularity and expanded cerebellum to whole-brain connectivity.

This report adds to the growing evidence-base for the involvement of the posterior cerebellum in the pathogenesis of OCD. Drawing conclusions from a single case study and the absence of a placebo treatment will prevent any confirmatory causal inferences from being made. The opportunity to examine network-changes that parallel therapeutic response in an individual with lesion-triggered psychiatric manifestations not only helps mapping symptoms to brain networks at an individual level 13 but also takes us a step further to refine methods to deliver more effective personalized-medicine in the years to come.

Data availability

Underlying data.

Harvard Dataverse: PICA OCD Raw fMRI files NII format. https://doi.org/10.7910/DVN/X12BZD 20 .

This project contains the following underlying data:

- postTMS_fmri.nii (raw post TMS fMRI file)

- preTMS_fmri.nii (Raw pre TMS fMRI file)

Reporting guidelines

Harvard Dataverse: PICA OCD case report CARE guidelines for case reports: 13-item checklist. https://doi.org/10.7910/DVN/2XKSXL 21 .

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).

Written informed consent for publication of their clinical details and clinical images was obtained from the patient.

Acknowledgments

We thank our patient and his parents for permitting us to collate this data for publication.

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Comments on this article Comments (0)

Open peer review.

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Cognitive neuroscience

• Respond or Comment
• COMMENT ON THIS REPORT

Is the background of the case’s history and progression described in sufficient detail?

Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?

Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?

Is the case presented with sufficient detail to be useful for other practitioners?

• This is a very interesting case report, even without the intervention component (which itself is a fascinating approach to neuromodulation). I particularly appreciated the approach to regional (SMA)
• This is a very interesting case report, even without the intervention component (which itself is a fascinating approach to neuromodulation). I particularly appreciated the approach to regional (SMA) targeting, which involved resting state fMRI to detect functional connectivity with the affected cerebellar region. The report itself is very clear and well-written.
• ECT appears to have been provided in the context of a depressive episode, but were other (e.g., psychotherapy, pharmacotherapy) treatments initially trialled? It would be useful to present any clinical history from adolescence, although this may not be feasible.
• Please describe the reason for conducting MRI; why was this not undertaken earlier?
• Was iTBS the “standard” course (i.e., 600 pulses, trains comprising 3 pulses at 50 Hz, repeated for 2 seconds at 5 Hz, followed by an 8-second ITI)? How was intensity determined (e.g., 70%RMT, 80%AMT)? Specify the stimulator, coil type, and neuronavigation method.
• Given that the duration of both the cerebellar lesion and OCD symptoms seems quite unclear, it is somewhat difficult to suggest a temporal relationship (as stated in the Conclusion).
• Was the patient followed-up over a longer-term period? I would be interested to know if these improvements are lasting (i.e., longer than 3 months), although again this might not be possible. 

Reviewer Expertise: Neuromodulation, psychiatry

• Author Response 11 Sep 2020 Urvakhsh Mehta , Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bangalore, 560029, India 11 Sep 2020 Author Response We thank this reviewer for the time taken to provide constructive feedback and the encouraging comments on this report.    Competing Interests: None We thank this reviewer for the time taken to provide constructive feedback and the encouraging comments on this report.    We thank this reviewer for the time taken to provide constructive feedback and the encouraging comments on this report.    Competing Interests: None Close Report a concern Reply -->

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• Shubhmohan Singh , Postgraduate Institute of Medical Education and Research, Chandigarh, India
• Peter Enticott , Deakin University, Geelong, Australia

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Obsessive-compulsive disorder: case study and discussion of treatment

Affiliation.

• 1 Department of Psychological Medicine, Hospitals for Sick Children, London.
• PMID: 2114137
• PMCID: PMC1371281

A patient's own account of her obsessive-compulsive disorder is presented. She describes her distressing experiences, the impact of the disturbance on her and her family's life and her subsequent improvement using the technique of exposure and response prevention. The treatments available are discussed and the benefits of self-directed behavioural psychotherapy are reviewed. A comment from a general practitioner is appended.

Publication types

• Case Reports
• Behavior Therapy*
• Obsessive-Compulsive Disorder* / psychology
• Obsessive-Compulsive Disorder* / therapy
• Psychotherapy

• International edition
• Australia edition
• Europe edition

I have OCD. Some cognitive behavioral therapy techniques were totally wrong for me

Many practitioners consider CBT the gold standard of therapy, but does it work for everyone?

T he first time I learned about cognitive behavioral therapy (CBT), I felt the pleasure of recognition and of superiority. I was in high school, and it would be years before I visited a therapist of any kind, but from what I gathered online, CBT consisted of what I was already doing.

The modality grew from a core belief that irrational thoughts are responsible for emotional suffering, according to Rachael Rosner, a historian writing a biography of Aaron Beck, the father of CBT. It followed that changing these thoughts could alleviate the distress.

Perhaps you’re afraid that your headache is a sign of a brain tumor. The CBT “ thought record ” technique might advise you to gather the facts for and against this fear. Is there a family history of brain tumors? Could the headache be caused by dehydration? Then, you reframe it into a more realistic, and presumably less panicked, position.

This back-and-forth volley already described my inner monologue. Years later, I chose for my first therapist one who practiced an old-school form of CBT that reinforced these habits.

It was easy to find such a therapist. Though exact statistics are scarce, CBT is a common modality. Many practitioners consider it the gold standard of psychotherapy and use it for conditions including anxiety and depression. By 2002, the Washington Post was claiming : “For better or worse, cognitive therapy is fast becoming what people mean when they say they are ‘getting therapy’.”

Its concepts “are very mainstream now”, says Sahanika Ratnayake, a philosopher of medicine and psychiatry. “You hear people talking about ‘cognitive distortions’ and ‘reframing your thoughts’ and this idea that how you think about something changes how you feel about it.”

Yet despite being fluent in these techniques, I remained trapped in rumination. Knowing all the cognitive distortions – types of negative bias or irrational thinking – didn’t lessen the worry. No matter how much evidence I gathered to prove that a worry was unlikely, I couldn’t forget that improbable things do happen. People were struck by lightning, planes did crash, headaches did turn out to be tumors. Eventually, I switched to psychodynamic therapy (more focused on feelings, more helpful for me) but continued my inner debate tournament.

Then, in my 30s, I was diagnosed with obsessive compulsive disorder (OCD), a condition marked by intrusive thoughts and physical or mental compulsions to get rid of the thoughts. This delay wasn’t uncommon: diagnosing OCD can take up to 14 to 17 years , in part because it can be hard to differentiate from other disorders such as anxiety. During that time, those thought-challenging techniques can backfire. They did for me.

T he story of modern CBT is, in part, the story of being in the right place at the right time: the US in the 1980s. After the Diagnostic and Statistical Manual of Disorders III, the handbook for diagnosing mental disorders, came out in 1980, the National Institute of Mental Health started requiring that researchers conduct randomized controlled trials for therapy if they wanted funding. By then, Rosner says, Beck had already created a manual for CBT so that it could be standardized and studied in this way. This meant CBT therapists could adapt quickly to the new rules, and the techniques took off.

As insurance companies warmed to CBT, therapists developing new modalities liked to associate with CBT too, partly so these forms could also be covered by insurance, according to Ratnayake. Today, CBT is a broad label that can include mindfulness skills and distress tolerance skills, for instance.

Still, it’s the original ideas around adapting irrational thoughts – the “cognitive” part of CBT – that seem to have trickled most into the mainstream. Behavioral and exposure-based CBT techniques are effective, but therapists can be less likely to use these methods , says Dean McKay, a psychology professor at Fordham University. Articles mentioning CBT tend to emphasize the “distorted thinking” aspect, as do most free worksheets – all contributing to the mistaken idea that CBT is primarily about being rational.

Cognitive techniques work for many. But “the typical OCD sufferer already knows the evidence”, adds McKay, who has researched the potential harms of CBT-type interventions . For them, evidence-gathering becomes just “another form of reassurance”. Reassurance (“of course you won’t die after eating food off the ground”) helps people with OCD feel better in the short term but reinforces the fear long term (“what if I’m the freak exception who will die?”), so they end up needing more and more comfort.

Katie O’Dunne, a minister and interfaith chaplain with OCD, experienced a compulsive cycle of reassurance related to intrusive fears about hurting others. Her therapist asked O’Dunne to list all the great things she’d done and remember that she was a nice person. It worked, briefly. Then her brain would start circling the same questions again: “It made the intrusive thoughts stronger because they would come back and find new ways to poke holes in the logic.”

O ddly enough, the first-line treatment for OCD is a form of CBT – just not the type that many would associate with the label. The difference in approach is clear in these practice phrases from a guidebook for people with OCD : There is no way I can guarantee I won’t stab my husband. Despite my best efforts, my neglect might cause a fire at work. I can’t be sure that my spouse will remain faithful to me.

This type of treatment, called exposure and response prevention (ERP), doesn’t try to dispute thoughts. It encourages patients to expose themselves to fears, either in a real or imagined situation , accept that it could happen – and not do anything to relieve the fear. Instead of reaching for the reams of evidence that you won’t stab your husband, live with the possibility that you might.

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To me, this approach was more helpful. As someone who would obsess over the 0.0001% chance I could be struck by lightning , acknowledging that chance feels like facing reality.

When I stopped trying to think rationally, my mind felt freed. I no longer needed to constantly remind myself to stop catastrophizing. I had permission to stop sifting through piles of research in a search for certainty. Instead, I started practicing ERP whenever the fears began. I can never be 100% certain that I won’t develop my mother’s disease , I would think, despite “knowing” that her illness was due (almost certainly) to bad luck.

At first, I flinched at the idea and pressure grew in my chest. But with time and repetition, my mind became less prone to these looping thoughts. And I began thinking about how this approach could help beyond OCD.

O ’Dunne, the chaplain, leads online groups for people navigating faith and OCD, but the community has started to include those without the disorder. “A lot of people who have navigated religious trauma or spiritual abuse or really rigid spiritual communities have been told for such a long time that they have to have certainty,” she says. “It’s been such a harmful dynamic.” To her, ERP isn’t just a treatment but rather “a beautiful, healthy lifestyle of uncertainty”.

In fact, “ intolerance of uncertainty ” is correlated with many conditions, including generalized anxiety, OCD, social anxiety and eating disorders, according to Mark Freeston , a psychologist at Newcastle University who has studied the concept since the 1990s. Instead of focusing on cognitive distortions, Freeston and collaborators help patients accept physical signals of uncertainty.

For example, patients play a children’s game where they pass around a spring-loaded toy. Because people know the outcome – the toy pops up – but not when it’ll happen, they learn to identify “temporal uncertainty” and realize that the feeling doesn’t mean a situation is dangerous. They can experience uncertainty and still be OK. In a study of group treatment that Freeston and his collaborators plan to submit for publication, they found that “making friends with uncertainty” helps decrease anxiety, even if the treatment never addresses a specific worry.

In the end, it’s not that challenging one’s thoughts doesn’t work (it can) or that behavioral strategies work for everyone (they won’t). Some people respond to evidence; they feel its rational force and are comforted. Others may prefer art therapy or internal family systems , a protocol that asks clients to work with different “parts” of their psyche. Approaches that involve analyzing the past can bring insight for some; for others, including people with OCD, focusing on the origin of intrusive thoughts can distract from getting better.

There are many reasons we might suffer, and no approach works for everyone – but for myself and many, with and without OCD, the cognitive form of CBT was the one most often held up to be obviously and generally helpful. For me, this led to simplistic and misguided understandings, both of CBT itself and of what I needed. I loved CBT’s cognitive strategies because the self-questioning came naturally, but for precisely that reason, I needed a treatment that did the opposite. I just wish it hadn’t taken so long.

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• Mental health
• Obsessive-compulsive disorder

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Study Notes

Explaining OCD

Last updated 22 Mar 2021

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In this and related study notes we focus on biological explanations and treatments for obsessive compulsive disorder (OCD).

Biological explanations are divided into genetic explanations and neural explanations .

Genetic explanations for OCD

Genetic explanations suggest OCD is inherited and that individuals inherit specific genes which cause OCD

Genetic explanations have focused on identifying particular genes which are implicated in OCD and two genes have been linked to OCD, including the COMT gene and SERT gene .

The COMT gene is associated with the production of , which regulates the neurotransmitter dopamine. One variation of the COMT gene results in higher levels of dopamine and this variation is more common in patients with OCD, in comparison to people without OCD.

A second gene which has been implicated in OCD is the SERT gene (also known as the 5-HTT gene). The SERT gene is linked to the neurotransmitter serotonin and affects the transport of the serotonin (hence SERotonin Transporter), causing lower levels of serotonin which is also associated with OCD (and depression)

Neural explanations for OCD

Neural explanations of OCD focus on neurotransmitters as well as brain structures .

Neural explanations suggest that abnormal levels of neurotransmitters , in particular serotonin and dopamine , are implicated in OCD.

Neural explanations also suggest that particular regions of the brain, in particular the basal ganglia and orbitofrontal cortex , are implicated in OCD.

Neurotransmitters

The neurotransmitter serotonin is believed to play a role in OCD. Serotonin regulates mood and lower levels of serotonin are associated with mood disorders, such as depression. Furthermore, some cases of OCD are also associated with the reduced levels of serotonin, which may be caused by the SERT gene (see above). Further support for the role of serotonin in OCD comes from research examining anti-depressants, which have found that drugs which increase the level of serotonin are effective in treating patients with OCD.

In addition, the neurotransmitter dopamine has also been implicated in OCD, with higher levels of dopamine being associated with some of the symptoms of OCD, in particular the compulsive behaviours.

Brain Structures

Two brain regions have been implicated in OCD, including the basal ganglia and orbitofrontal cortex.

The basal ganglia is a brain structure involved in multiple processes, including the coordination of movement. Patients who suffer head injuries in this region often develop OCD-like symptoms, following their recovery. Furthermore, Max et al. (1994) found that when the basal ganglia is disconnected from the frontal cortex during surgery, OCD-like symptoms are reduced, providing further support for the role of the basal ganglia in OCD.

Another brain region associated with OCD is the orbitofrontal cortex , a region which converts sensory information into thoughts and actions. PET scans have found higher activity in the orbitofrontal cortex in patients with. One suggestion is that the heightened activity in the orbitofrontal cortex increases the conversion of sensory information to actions (behaviours) which results in compulsions. The increased activity also prevents patients from stopping their behaviours.

One strength of the biological explanation of OCD comes from research from family studies. Lewis (1936) examined patients with OCD and found that 37% of the patients with OCD had parents with the disorder and 21% had siblings who suffered. Research from family studies, like Lewis, provide support for a genetic explanation to OCD, although it does not rule out other (environmental) factors playing a role.

Further support for the biological explanation of OCD comes from twin studies which have provided strong evidence for a genetic link. Nestadt et al. (2010) conducted a review of previous twin studies examining OCD. They found that 68% of identical twins and 31% of non-identical twins experience OCD, which suggests a very strong genetic component.

Support for the neural explanations of OCD come from research examining biological treatments including anti-depressants.

Anti-depressants typically work by increasing levels of the neurotransmitter serotonin . These drugs are effective in reducing the symptoms of OCD and provide support for a neural explanation of OCD.

Extension: However, no twin study has found a concordance rate of 100% in identical twins, which means that biological factors are not the only factor contributing to OCD and there must be environmental factors which also contribute to this disorder.

One weakness of the biological explanation for OCD is that it ignores other factors and is reductionist. For example, the biological approach does not take into account cognitions (thinking) and learning. Some psychologists suggest that OCD may be learnt through classical conditioning and maintained through operant conditioning stimulus (for example, dirt) is associated with anxiety and this association is then maintained through operant conditioning, where a person avoids dirt and continually washes their hands. This hand washing reduces their anxiety and negatively reinforces their compulsions.

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• Nestadt et al. (2010)
• Lewis (1936)
• Max et al. (1994)

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