CBT for Obsessive Compulsive Disorder (OCD)
Discover how CBT can effectively address the challenges of OCD, helping individuals break free from the cycle of obsessive thoughts and compulsive behaviours.
What is Obsessive Compulsive Disorder (OCD)?
Obsessive compulsive disorder (OCD) is a mental health condition characterized by recurring, uncontrollable thoughts (obsessions), often leading to repetitive behaviours (compulsions). These obsessions and compulsions interfere with daily life and cause significant distress.
While many individuals with OCD experience both obsessions and compulsions, some may have only one of the two.
Obsessions are unwanted, intrusive thoughts, images, or urges that provoke distress, often accompanied by uncomfortable and intense feelings such as doubt, fear, and disgust. Individuals with OCD usually recognize that these thoughts are irrational.
Compulsions are repetitive behaviours or rituals performed to reduce the anxiety and distress caused by obsessions. Though people with OCD often know these behaviours offer only temporary relief, they find it difficult to resist them.
Individuals with OCD may have rituals, which are behaviours that the person feels a strong urge to do. They can include checking and re-checking if something is turned off or locked, repetitively washing and cleaning, or arranging objects in just the right order.
Cognitive behavioural therapy (CBT) helps individuals with OCD transform negative or unhelpful thought patterns and behaviours into more constructive ones. This evidence-based therapy is widely recognized for its effectiveness in treating OCD symptoms. Studies involving over 1,600 participants showed that CBT reduced OCD symptoms by 59.2% immediately after treatment and 57.0% at follow-up.
Causes and Symptoms of OCD
There is no singular cause of OCD, but multiple risk factors can contribute to its development, including:
- Genetics: Studies have shown that individuals with a close relative (such as a parent or sibling) who has OCD are at higher risk of developing the disorder.
- Childhood trauma: Research has linked childhood trauma, such as neglect or abuse, to the onset of OCD.
- Brain changes: People with OCD may have differences in the frontal cortex and subcortical structures of their brain, which impact the ability to control emotional and behavioural responses.
- Temperament: Individuals who are more reserved, experience negative emotions, and suffer from anxiety and depression in childhood are more likely to develop OCD.
- PANDAS syndrome: “Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections” describes a group of conditions, including OCD, that may affect those who have had strep infections as a child.
Common symptoms of OCD obsessions may include:
- Fear of being contaminated after touching high-contact objects
- Stress or anxiety when objects aren’t facing a certain way or orderly
- Fear of forgetting or losing things
- Worry about losing control or making a mistake
- Feelings of doubt or disgust
- Constant need for reassurance
Common OCD compulsions may include:
- Counting in specific patterns
- Excessive hand-washing or cleaning
- Checking doors over and over again to make sure they’re locked
- Checking the oven multiple times to make sure it’s turned off
- Silently repeating words, phrases, or prayers
- Arranging things in a very specific way
Obsessions and compulsions typically revolve around themes that are commonly seen as:
- Constant checking and re-checking
- Fear of contamination
- Ruminating and intrusive thoughts
- Symmetry and ordering
- Washing and cleaning
How does CBT Treat OCD?
Cognitive behavioural therapy (CBT) teaches individuals to recognize how their thoughts, feelings, and behaviours are interconnected. In the context of OCD, CBT helps individuals break the automatic association between anxiety-inducing situations and ritualistic behaviours.
The specific CBT technique for OCD is called Exposure and Ritual Prevention (ERP), designed to disrupt two key associations that occur in OCD:
- The link between distress and the situations, objects, or thoughts that trigger it.
- The association between ritual behaviours and temporary relief from anxiety or distress.
ERP involves three main components:
- In Vivo Exposure: Known as “actual” or “real-life” exposure, in-vivo involves staying in the presence of a feared situation or object that evokes anxiety or distress for longer periods (i.e. touching a doorknob and resisting the urge to wash one’s hands).
- Imaginal Exposure: This involves visualizing oneself in the feared situations or the consequences of those situations (i.e. visualizing driving on the road and hitting another car).
- Ritual Prevention: Avoiding ritualistic behaviours to break the cycle of compulsions (i.e. leaving the house without checking if the door is locked).
Why Should I Do Exposure and Ritual Prevention (ERP)?
Exposure and ritual prevention (ERP) teaches individuals with OCD how to respond differently to their triggers, leading to less frequent compulsions and less intense obsessions. The three main steps are:
1. In Vivo Exposure
Individuals with OCD work on confronting feared situations and objects in “real life,” allowing anxiety to subside naturally. The therapist designs situations and guides the individual in resisting compulsions. During the exposures, the patient will avoid performing ritualistic behaviours for increased periods, thus realizing their anxiety may increase but will eventually subside. Over time, anxiety decreases, and the individual feels less uncomfortable in similar situations.
2. Imaginal Exposure
For situations that cannot be replicated (such as catastrophic fears), the therapist guides the patient through detailed visualizations. In imaginal exposure, the individual creates detailed images of the disaster they feel will happen if they do not perform ritualistic behaviours. Although distress may initially rise, it will decrease over time, similar to in-vivo exposure.
3. Ritual Prevention
Ritual prevention is designed to break the habit of ritualizing, even if one still has urges. Rituals may be difficult to stop because they bring relief from discomfort or anxiety, but they get in the way of one’s life. In treatment, the therapist teaches the patient alternative coping mechanisms to manage discomfort.
Mindful CBT Lessons for OCD Recovery
CBT breaks recovery down into smaller, actionable steps, reducing the overwhelming nature of OCD. Here are some important lessons for OCD recovery:
Understanding your OCD
There are many subtypes of OCD, and everyone’s is different. It is essential to understand the specific triggers, thoughts, and behaviours associated with one’s OCD. Keeping a record of triggers and responses can help increase self-awareness and improve management of symptoms. When armed with this knowledge, individuals can increase their awareness and ability to intercept when the OCD cycle kicks in.
Everyone has intrusive thoughts
Everyone has intrusive thoughts, but individuals with OCD place greater weight on them, believing they are more significant or likely to occur. In treatment, they learn to put less weight and validity on these thoughts and reduce compulsive behaviours.
Dysfunctional beliefs
Also known as cognitive distortions, dysfunctional beliefs can be experienced by anyone. When paired with OCD, it can worsen the symptoms and make one more vulnerable to them. Identifying and understanding these beliefs can help individuals reduce their vulnerability to OCD.
Thought-action fusion
Those with OCD often unknowingly fuse their thoughts or mental images with reality, making their intrusive thoughts feel more threatening. Treatment helps individuals differentiate between their thoughts and reality, reducing the fear that thinking about something makes it more likely to happen.
Other CBT Methods to Treat OCD
I-CBT Treatment
Also called inferential confusion, I-CBT treatment for OCD focuses on unwinding the process in which one confuses what is happening within oneself with what is happening in reality. Patients learn to understand experiences as they exist in real life, not within the “OCD story” they have developed.
Cognitive Therapy
This approach teaches individuals how OCD works and why intrusive thoughts trigger such intense feelings of distress and anxiety. They learn how to give these thoughts less weight, validity, and attention and how to confront the obsessions by responding to them in more positive ways. Treatment strategies can include self-talk and challenging the probability of feared events.
Meta-Cognitive Therapy (MCT)
Individuals are taught to ignore intrusive thoughts by learning to emotionally detach from the obsession and observe it without judgment. MCT helps change one’s perception of the significance of intrusive thoughts and the need to react to them so they no longer seem important or factual.
Journaling
Consistently recording intrusive thoughts and corresponding compulsive behaviours increases self-awareness of patterns and triggers, helping individuals track progress. For example, one may write down the obsessive thought, “I have touched a dirty doorknob,” and the resulting compulsive behaviour of washing their hands for ten minutes.
Mindfulness
Mindfulness exercises teach individuals to observe their obsessive thoughts without reacting to them. This helps develop a sense of detachment from the thoughts, weakening their hold and influence.
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Frequently Asked Questions
The OCD thought loop can be distressing and exhausting. Some strategies to help stop thought loops include accepting the thoughts instead of pushing them away, sharing your thoughts with a trusted person, and focusing on a simple but engaging task.
The 15-minute rule helps individuals learn to resist OCD symptoms by letting at least 15 minutes pass before considering acting on the thought or urge. After the short period has elapsed, reassess the urge and feelings, which will likely have decreased.
OCD is challenging to treat because of the self-induced cycle of obsessions and compulsions. When someone with OCD has an intrusive thought, they feel compelled to act on certain rituals to alleviate their distress and anxiety. The compulsion only provides temporary relief, causing the obsessions to return even stronger.