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James Pretzer August 26th, 2005 09:49 PM

Understanding Obsessive-compulsive Disorder
We have some effective treatments for OCD but it remains a tough problem to treat. A number of investigators have een working to develop a better understanding of OCD in the hope that this will lead to more effective interventions. Individuals with OCD often manifest an excessively strong sense of personal responsibility. In addition, they often express a strong conviction that thoughts and feelings are dangerous and must be controlled. A recent study looks at how these relate to OCD symptoms:

Myers, S. G. & Wells, A. (2005). Obsessive-compulsive symptoms: The contribution of metacognitions and responsibility. Journal of Anxiety Disorders, 19, 806-817.

ABSTRACT: Two different models of obsessive-compulsive symptoms were evaluated. One model [Salkovkis, P. M. (1985). Obsessional-compulsive problems a cognitive-behavioral analysis. Behaviour Research and Therapy, 23, 571-583.] gives a central and necessary role to beliefs and appraisals concerning responsibility. The other [Wells, A. (1997). Cognitive therapy of anxiety disorders: a practice manual and conceptual guide. Chichester, UK: Wiley.] attaches a central and necessary role to metacognitive beliefs about the meaning and danger of thoughts/feelings and the need for control. We tested the unique contributions of responsibility or metacognitions to obsessive-compulsive symptoms whilst controlling for their intercorrelations and worry. Consistent with each model, responsibility and metacognitions were positively associated with obsessive-compulsive symptoms, even when worry was controlled for. However, responsibility was not associated with obsessive-compulsive symptoms when metacognitions and worry were controlled, but the relationship between metacognitive beliefs and obsesssive-compulsive symptoms was independent of responsibility and worry. Responsibility did not add anything to the variance in symptoms explained by metacognitions. The data provide further support for the metacognitive model.

James Pretzer August 28th, 2005 09:34 PM

Understanding Obsessive-compulsive Disorder II
Intolerance of uncertainty is another common feature of OCD. A recent self-help book (Freedom from obsessive-compulsive disorder: A personalized recovery program for living with uncertainty by J. Grayson) differs from the other good self-help books on OCD by focusing extensively on tolerating uncertainty.

I haven't seen the book myself but Alec Pollard reviewed it in the Summer 2005 volume of Cognitive and Behavioral Practice. Alec knows OCD really well and his review makes it sound as though the book would be useful in understanding how intolerance of uncertainty fits into OCD (and would be useful for clients too).

James Pretzer April 28th, 2006 08:56 PM

Understanding Obsessive-compulsive Disorder III
While psychological factors are important in OCD and are an important focus for intervention, let's not forget that biology seems to play an important role as well. A genetic variation has been identified that doubles the incidence on OCD. For details see

Neil Levitsky April 28th, 2006 10:37 PM

Re: Understanding Obsessive-compulsive Disorder
Interesting article!
I'm quite interested in OCD; I see a fair bit of it in my practice. This article makes me think of an excellent review book :Cognitive Behavioral Therapy Of OCD, by David Clark (the Canadian David Clark, as opposed to the British David Clark), which is a recent text giving a superb overview of theory, treatment, etc.
Clark's view, I think, essentially considers both components, Salkovskis' and the metacognitive. If I understand his formulation (and please excuse me if I am totally misstating it), there are 2 problems with OCD. the first is a distorted interpretation of the intrusion itself; this would be where the classic OCD distortions of excessive responsibility, intolerance of uncertainty, etc come into play (I believe the Obsessive Compulsive Cognitions Working Group has a specific list). Then, there is a secondary appraisal, of how well controlled the intrusion was. this sounds like the idea of a metacognition; I am curious if others would agree, or am I missing something?

While I'm at it, any suggestions from anyone on helping an OCD patient who suffers from perfectionistic patterns of fearing making any mistake. He ends up taking hugely excessive amounts of time buying things, paying bills, filling out forms, etc, because each decision has to be thought through to make sure it is the right one. He won't let a grocery checkout clerk start scanning items until everything is on the belt, because he feels he has to watch for any mistakes. Aside from challenging the belief "I must not make mistakes", and doing exposure via intentional mistakes or setting time limits on tasks, any other suggestions?

Carl Robbins April 30th, 2006 05:33 AM

Re: Understanding Obsessive-compulsive Disorder
Is your patient's perfectionism an indication of OCPD (Obsessive Compulsive Personality Disorder), rather than OCD? Is the need to be so careful about money driven by anxiety or by a insistence on being right and, perhaps, excessively frugal?

Steve Phillipson has a superb article on the distinction between OCPD and OCD entitled, "The Right Stuff...A Defect of Philosophy, not Anxiety."

I'd like to hear suggestions on the differences between treating OCD vs. OCPD. It seems that exposure would be less important in the latter condition.

Also, I've used Grayson's book extensively with clients in my private practice. There is a great chapter discussing the importance of cultivating tolerance for uncertainty in GAD, Hyponchodriasis, and Body Dysmorphic Disorder. Grayson includes a number of scripts that can be used to enhance and support exposure.

Neil Levitsky May 1st, 2006 05:01 PM

Re: Understanding Obsessive-compulsive Disorder
Re: whether this patient's perfectionism is more OCPD than OCD, I think that's a very good question that I may have overlooked. Then again, I'm not sure the treatment would differ a lot; whether refractory OCD or OCPD, tackling underlying assumptions and core beliefs would likely be part of it. Also, exposure presumably could help with both conditions.

I haven't seen Grayson's book, but sounds like it's worth getting. I guess I've held off buying yet more OCD books, since I have self help manuals by Steketee and by Hyman and Pedrick, as well as Foa and Wilson's "Stop Obsessing". My favorite currently is Hyman and Pedricks manual - does anyone have that one and also Grayson's, and if so, how do they compare?

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