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ACT for OCD: Key Initial Concepts

By Kate Morrison, Ph.D.

This video is part of our upcoming online course about ACT for OCD.

Highlights

  • OCD consists of distressing intrusive thoughts, images, or urges, obsessions, and compulsions.
  • They have a negative impact on the person’s life.
  • Thought patterns are intolerance of uncertainty and higher perception of risk.
  • Thoughts reflect on the person’s character and make actions more likely.

 

Transcript

Hi and welcome to ACT for OCD.

My name is Dr. Kate Morrison and I am a psychologist in Salt Lake City, Utah. And I’m in private practice and most of my career has been in researching and practicing acceptance and commitment therapy—especially with anxiety and OCD and related disorders. So today, I’m going to share some of what I’ve learned through this process of working with these disorders and using ACT. And so we are going to start with general concepts about what OCD is. So today, I’m going to introduce to you these general concepts of OCD and ACT.

So, obsessive-compulsive disorder among adults in the United States is about 1% to 2% for a 12-month prevalence rate and about 2.3% for a lifetime prevalence rate. And in adulthood, women tend to be at a slightly higher rate than men. However, in childhood, men tend to have a higher rate than women do.

References

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.

Ruscio, A. M., Stein, D. J., Chiu, W. T., & Kessler, R. C. (2008). The epidemiology of obsessive-compulsive disorder in the national comorbidity survey replication. Molecular Psychiatry, 15, 53–63.

Weissman, M. M., Bland, R. C., Canino, G. J., Greenwald, S., Lee, C.-K., Newman, S. C., Rubio-Stipec, M., & Wickramaratne, P. J. (1996). The cross-national epidemiology of social phobia: A preliminary report. International Clinical Psychopharmacology, 11(Supplement 3), 9–14.

And in OCD, there are three main components that you want to be aware of, and these are obsessions, compulsions, and the disorder aspect of that name.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

So, obsessions, what you want to be thinking about is the internal experiences that people are having. And for OCD, this includes intrusive, unwanted, and distressing thoughts or distressing images or intense urges that they may be experiencing to do a certain behavior.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

On the behavior side of things, we’ll call these compulsions within OCD. And these are repetitive behaviors that are with the intention to reduce the distress that is associated with the obsessions, and that is also with the intention to reduce a perceived threat. So, if someone has the belief that if they don’t check their stove that something bad might happen—their house may catch on fire. So, the intention there would not necessarily be just to reduce the distress that they’re feeling but also to reduce the likelihood that their home would catch on fire. So, that would be the perceived threat.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

And then the disorder part of the word or of the phrase is just referring to that these symptoms, in order for it to be OCD, need to have a negative impact on the person’s functioning, either through heightened distress or through, not being able to function in their daily life. Or the compulsions or the obsessions are so time consuming that it’s really having a negative impact on their quality of life.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

And the reason the disorder piece is important here is because obsessions and compulsions, or at least intrusive thoughts and engaging in behaviors to try to reduce those, are actually more common than OCD itself. So, people have tendencies toward OCD, but for it to be classified as the disorder, there needs to be that negative impact on the person’s life.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Some common themes of OCD. So, these are themes that obsessions and compulsion will center around.

Contamination is a pretty common one. That’s the one that OCD is most well known for and that’s either contracting something themselves or spreading it to other people.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

McKay, D., Abramowitz, J. S., Calamari, J. E., Kyrios, M., Radomsky, A., Sookman, D., Taylor, S., & Wilhelm, S. (2004). A critical evaluation of obsessive-compulsive disorder subtypes: Symptoms versus mechanisms. Clinical Psychology Review, 24(3), 283–313. 

Williams, M. T., Farris, S. G., Turkheimer, E. N., Franklin, M. E., Simpson, H. B., Liebowitz, M., & Foa, E. B. (2014). The impact of symptom dimensions on outcome for exposure and ritual prevention therapy in obsessive-compulsive disorder. Journal of Anxiety Disorders, 28(6), 553–558.

They can also have thoughts of harm to themselves or to others. And these can be intrusive violent images or just being concerned that they might accidentally harm themselves or other people.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

McKay, D., Abramowitz, J. S., Calamari, J. E., Kyrios, M., Radomsky, A., Sookman, D., Taylor, S., & Wilhelm, S. (2004). A critical evaluation of obsessive-compulsive disorder subtypes: Symptoms versus mechanisms. Clinical Psychology Review, 24(3), 283–313.

Williams, M. T., Farris, S. G., Turkheimer, E. N., Franklin, M. E., Simpson, H. B., Liebowitz, M., & Foa, E. B. (2014). The impact of symptom dimensions on outcome for exposure and ritual prevention therapy in obsessive-compulsive disorder. Journal of Anxiety Disorders, 28(6), 553–558.

Sexual thoughts are within this theme. You see things that are common, like fears of pedophilia, some taboo sexual thoughts, so maybe just thoughts that are inconsistent with how they see themselves and how they are as a sexual being.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

McKay, D., Abramowitz, J. S., Calamari, J. E., Kyrios, M., Radomsky, A., Sookman, D., Taylor, S., & Wilhelm, S. (2004). A critical evaluation of obsessive-compulsive disorder subtypes: Symptoms versus mechanisms. Clinical Psychology Review, 24(3), 283–313.

Williams, M. T., Farris, S. G., Turkheimer, E. N., Franklin, M. E., Simpson, H. B., Liebowitz, M., & Foa, E. B. (2014). The impact of symptom dimensions on outcome for exposure and ritual prevention therapy in obsessive-compulsive disorder. Journal of Anxiety Disorders, 28(6), 553–558.

Also, sexual orientation can fall within this, so sexual orientation and gender identity. With these, I think it’s important to clarify that this is not someone questioning their sexuality or questioning their gender identity. This is for someone who is very much settled within either their orientation or gender identity and they are having persistent questioning and doubt if that is accurate. And so this is different than if someone is truly realizing that they may have a different orientation or identity. Within the sexual realm, this can also include thoughts about incest, thoughts related to religious leaders or deities, so this can be very distressing for people.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

McKay, D., Abramowitz, J. S., Calamari, J. E., Kyrios, M., Radomsky, A., Sookman, D., Taylor, S., & Wilhelm, S. (2004). A critical evaluation of obsessive-compulsive disorder subtypes: Symptoms versus mechanisms. Clinical Psychology Review, 24(3), 283–313.

Williams, M. T., Farris, S. G., Turkheimer, E. N., Franklin, M. E., Simpson, H. B., Liebowitz, M., & Foa, E. B. (2014). The impact of symptom dimensions on outcome for exposure and ritual prevention therapy in obsessive-compulsive disorder. Journal of Anxiety Disorders, 28(6), 553–558.

Religious and moral obsession themes are also referred to as scrupulosity and again, this doesn’t fall within the realm of typical religious and moral beliefs. This is when someone is especially cautious and careful and goes beyond what is appropriate for their religion or for their culture. So, this could be something like questioning how truthful they were about something and questioning that in every interaction that they have with people. And then they might end up excessively praying or excessively speaking with a clergy member to ask for forgiveness or speaking with others to get reassurance.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

McKay, D., Abramowitz, J. S., Calamari, J. E., Kyrios, M., Radomsky, A., Sookman, D., Taylor, S., & Wilhelm, S. (2004). A critical evaluation of obsessive-compulsive disorder subtypes: Symptoms versus mechanisms. Clinical Psychology Review, 24(3), 283–313.

Williams, M. T., Farris, S. G., Turkheimer, E. N., Franklin, M. E., Simpson, H. B., Liebowitz, M., & Foa, E. B. (2014). The impact of symptom dimensions on outcome for exposure and ritual prevention therapy in obsessive-compulsive disorder. Journal of Anxiety Disorders, 28(6), 553–558.

The just right and symmetry theme of OCD, it’s a bit more unique because often, there is not a specific belief of something bad happening here. And so what this is more likely to be is that someone just has a feeling that something is off. And so it shows up more as a physical sensation or something just doesn’t quite feel right, but they can’t usually articulate that there’s something bad that will happen. Sometimes, it might be like, “Oh, I may never stop having this feeling,” or “It’s so uncomfortable. I need to do something to get it to go away. I don’t know if I can handle this. I might go crazy.”

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

McKay, D., Abramowitz, J. S., Calamari, J. E., Kyrios, M., Radomsky, A., Sookman, D., Taylor, S., & Wilhelm, S. (2004). A critical evaluation of obsessive-compulsive disorder subtypes: Symptoms versus mechanisms. Clinical Psychology Review, 24(3), 283–313.

Williams, M. T., Farris, S. G., Turkheimer, E. N., Franklin, M. E., Simpson, H. B., Liebowitz, M., & Foa, E. B. (2014). The impact of symptom dimensions on outcome for exposure and ritual prevention therapy in obsessive-compulsive disorder. Journal of Anxiety Disorders, 28(6), 553–558.

But these don’t usually have other themes of something bad happening, so this would be something like wanting books to be aligned a certain way or wanting to see your bank account be at the exact, even number or right on the dollar rather than it being off by a bit.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

McKay, D., Abramowitz, J. S., Calamari, J. E., Kyrios, M., Radomsky, A., Sookman, D., Taylor, S., & Wilhelm, S. (2004). A critical evaluation of obsessive-compulsive disorder subtypes: Symptoms versus mechanisms. Clinical Psychology Review, 24(3), 283–313.

Williams, M. T., Farris, S. G., Turkheimer, E. N., Franklin, M. E., Simpson, H. B., Liebowitz, M., & Foa, E. B. (2014). The impact of symptom dimensions on outcome for exposure and ritual prevention therapy in obsessive-compulsive disorder. Journal of Anxiety Disorders, 28(6), 553–558.

And obsessions and compulsions can be any theme. The ones that I’ve described are simply the ones that tend to be more common, but as long as there’s this theme of an intrusive unwanted thought or image or urge and then repetitive behaviors to reduce that or the perceived threat, then it can be any theme. And you often see that people don’t always fall into this or into these categories.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

McKay, D., Abramowitz, J. S., Calamari, J. E., Kyrios, M., Radomsky, A., Sookman, D., Taylor, S., & Wilhelm, S. (2004). A critical evaluation of obsessive-compulsive disorder subtypes: Symptoms versus mechanisms. Clinical Psychology Review, 24(3), 283–313.

Williams, M. T., Farris, S. G., Turkheimer, E. N., Franklin, M. E., Simpson, H. B., Liebowitz, M., & Foa, E. B. (2014). The impact of symptom dimensions on outcome for exposure and ritual prevention therapy in obsessive-compulsive disorder. Journal of Anxiety Disorders, 28(6), 553–558.

Depression is a common comorbidity with OCD. And the reason that I mention this is because I especially would want you to assess for suicidality—especially when the belief’s that if the person with OCD were to not be alive that they would not be able to cause harm to other people, so when there’s harm-related obsessions. Sometimes, this can come up because they have so much doubt and so much distress that they could potentially do something to people they love. So they would rather harm themselves and end their life instead of having that be a risk.

References

Brakoulias, V., Starcevic, V., Belloch, A., Brown, C., Ferrao, Y. A., Fontenelle, L. F., Lochner, C., Marazziti, D., Matsunaga, H., Miguel, E. C., Reddy, Y. C. J., do Rosario, M. C., Shavitt, R. G., Shyam Sundar, A., Stein, D. J., Torres, A. R., & Viswasam, K. (2017). Comorbidity, age of onset and suicidality in obsessive-compulsive disorder (OCD): An international collaboration. Comprehensive Psychiatry, 76, 79–86.

Brown, T. A., Campbell, L. A., Lehman, C. L., Grisham, J. R., & Mancill, R. B. (2001). Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. Journal of Abnormal Psychology, 110(4), 585–599.

Ruscio, A. M., Stein, D. J., Chiu, W. T., & Kessler, R. C. (2008). The epidemiology of obsessive-compulsive disorder in the national comorbidity survey replication. Molecular Psychiatry, 15, 53–63.

There are common thought patterns within OCD and the primary one is an intolerance of uncertainty. And this can be, at times, more difficult for someone to experience than the feared outcome itself. And so this can be a difficulty, experiencing not knowing if something bad will happen or the unknown, if they definitely turned something off or definitely checked something.

References

Brown, T. A., Campbell, L. A., Lehman, C. L., Grisham, J. R., & Mancill, R. B. (2001). Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. Journal of Abnormal Psychology, 110(4), 585–599.

Obsessive Compulsive Cognitions Working Group. (2003). Psychometric validation of the obsessive beliefs questionnaire and the interpretation of intrusions inventory: Part I. (2003). Behaviour Research and Therapy, 41(8), 863–878.

Obsessive Compulsive Cognitions Working Group. (2005). Psychometric validation of the obsessive belief questionnaire and interpretation of intrusions inventory—Part 2: Factor analyses and testing of a brief version. Behaviour Research and Therapy, 43(11), 1527–1542.

Another one is the perceived risk that is there. Someone with OCD tends to see the risk to be higher than others. They may perceive themselves to have a higher level of responsibility for events. And they might believe that they can’t handle a certain amount of distress or that the distress may never end, and so they need to do something to stop it. They also may have the belief that having what they would call bad thoughts means that they themselves are bad, so they see a connection between those when, in reality, the thoughts we have don’t actually match or don’t have to match who we are as a person.

References

Obsessive Compulsive Cognitions Working Group. (1997). Cognitive assessment of obsessive-compulsive disorder. Behaviour Research and Therapy, 35(7), 667–681.
Obsessive Compulsive Cognitions Working Group. (2003). Psychometric validation of the obsessive beliefs questionnaire and the interpretation of intrusions inventory: Part I. (2003). Behaviour Research and Therapy, 41(8), 863–878.

Obsessive Compulsive Cognitions Working Group. (2005). Psychometric validation of the obsessive belief questionnaire and interpretation of intrusions inventory—Part 2: Factor analyses and testing of a brief version. Behaviour Research and Therapy, 43(11), 1527–1542.

And then they may also have the belief that having a thought is equal to doing an action or that it makes the action more likely. So, as you can imagine, it’ll be very distressing if you’re having thoughts that are very inconsistent with who you are and then you have the belief that that’s just as bad as doing that action itself.

References

Obsessive Compulsive Cognitions Working Group. (1997). Cognitive assessment of obsessive-compulsive disorder. Behaviour Research and Therapy, 35(7), 667–681.
Obsessive Compulsive Cognitions Working Group. (2003). Psychometric validation of the obsessive beliefs questionnaire and the interpretation of intrusions inventory: Part I. (2003). Behaviour Research and Therapy, 41(8), 863–878.

Obsessive Compulsive Cognitions Working Group. (2005). Psychometric validation of the obsessive belief questionnaire and interpretation of intrusions inventory—Part 2: Factor analyses and testing of a brief version. Behaviour Research and Therapy, 43(11), 1527–1542.

And then when looking at compulsions and rituals, one important thing to know is that they don’t need to match the obsession. So, someone doesn’t have to wash their hands in order to stop spreading germs. There’s a logical connection between those two, but it doesn’t have to be that way.

References

Foa, E. B., Kozak, M. J., Goodman, W. K., Hollander, E., Jenike, M. A., & Rasmussen, S. A. (1995). DSM-IV field trial: Obsessive-compulsive disorder. American Journal of Psychiatry, 152(1): 90–96.

Obsessive Compulsive Cognitions Working Group. (1997). Cognitive assessment of obsessive-compulsive disorder. Behaviour Research and Therapy, 35(7), 667–681.
Obsessive Compulsive Cognitions Working Group. (2003). Psychometric validation of the obsessive beliefs questionnaire and the interpretation of intrusions inventory: Part I. (2003). Behaviour Research and Therapy, 41(8), 863–878.

Obsessive Compulsive Cognitions Working Group. (2005). Psychometric validation of the obsessive belief questionnaire and interpretation of intrusions inventory—Part 2: Factor analyses and testing of a brief version. Behaviour Research and Therapy, 43(11), 1527–1542.

The rituals can be things that are completely detached from it, where it doesn’t have to logically connect. So, that would be if I tap on my desk 3 times, that will stop an earthquake from happening a thousand miles away. Those 2 things are not related, but if there is the belief that that behavior is tied to that obsession or to that event, then that still falls within this realm.

References

Foa, E. B., Kozak, M. J., Goodman, W. K., Hollander, E., Jenike, M. A., & Rasmussen, S. A. (1995). DSM-IV field trial: Obsessive-compulsive disorder. American Journal of Psychiatry, 152(1): 90–96.

Obsessive Compulsive Cognitions Working Group. (1997). Cognitive assessment of obsessive-compulsive disorder. Behaviour Research and Therapy, 35(7), 667–681.
Obsessive Compulsive Cognitions Working Group. (2003). Psychometric validation of the obsessive beliefs questionnaire and the interpretation of intrusions inventory: Part I. (2003). Behaviour Research and Therapy, 41(8), 863–878.

Obsessive Compulsive Cognitions Working Group. (2005). Psychometric validation of the obsessive belief questionnaire and interpretation of intrusions inventory—Part 2: Factor analyses and testing of a brief version. Behaviour Research and Therapy, 43(11), 1527–1542.

And something that clients are often unaware of is that there are mental rituals or compulsions that can serve the same purpose. So often, people think of compulsions and rituals being a behavior that you do and something that’s external, which, in fact, is a behavior. It’s just something that’s happening internally. And so these can be very subtle and much more difficult for clients to catch, but these are things like providing themselves with reassurance or telling themselves “Oh, I would never do that,” or doing counting within their head, or praying.

References

Foa, E. B., Kozak, M. J., Goodman, W. K., Hollander, E., Jenike, M. A., & Rasmussen, S. A. (1995). DSM-IV field trial: Obsessive-compulsive disorder. American Journal of Psychiatry, 152(1): 90–96.

Obsessive Compulsive Cognitions Working Group. (1997). Cognitive assessment of obsessive-compulsive disorder. Behaviour Research and Therapy, 35(7), 667–681.
Obsessive Compulsive Cognitions Working Group. (2003). Psychometric validation of the obsessive beliefs questionnaire and the interpretation of intrusions inventory: Part I. (2003). Behaviour Research and Therapy, 41(8), 863–878.

Obsessive Compulsive Cognitions Working Group. (2005). Psychometric validation of the obsessive belief questionnaire and interpretation of intrusions inventory—Part 2: Factor analyses and testing of a brief version. Behaviour Research and Therapy, 43(11), 1527–1542.

Okay, let’s go over the key points. Obsessive-compulsive disorder consists of distressing intrusive thoughts, images, or urges; the excessive repetitive behaviors, which can be mental and physical; and then the compulsions.
 
This needs to have a negative impact on the person’s life.

The common thought patterns are intolerance of uncertainty, that they have a higher perception of risk and responsibility. They believe that their thoughts reflect poorly on their character and that their thoughts make their actions more likely and that they have an intolerance of distress.

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