Studies have shown that actually using both behavioral therapy and pharmacology together can best help the patient achieve optimal results.
Obsessions again are repetitive and
persistent thoughts, images or urges,
and these are not experienced
as pleasurable at all.
Compulsions are rituals or mental acts
that an individual feels driven to perform
in an effort to neutralize their thoughts.
Urges to harm one’s self
or others is extremely
important to illicit in
your history of the patient
and if you do find that the patient,
maybe while presenting
with OCD type symptoms,
is also having self-injurious or
thoughts of hurting other people.
It’s really important that
you take further action
immediately to keep them and others safe.
So, we’re going to go through some
examples now of obsessions and compulsions
and I’d like you to take a guess
at where these appropriately fit.
So what are mental acts?
Well, mental acts can be compulsions.
Repeating words or numbers
silently, again, are compulsions.
Repetitive behaviors are compulsions.
Counting is a compulsion.
Images of violent scenes, this
would be obsessional thoughts,
and urges like thinking about
stabbing or hurting someone else,
that’s also an obsessional thought.
How about contamination or
fears of contamination?
That’s again an obsession.
And what about washing, repetitive washing?
That’s a compulsion.
Checking things over and over again,
that’s another example of a compulsion.
So, Jane's obsessions are often handled
by attempting to ignore, avoid,
suppress or neutralize them
with another thought or action.
Compulsions are often used to
neutralize these recurrent,
intrusive, and unwanted
thoughts, images or urges.
Jane's aim is to reduce
the distress triggered
by obsessions or to
prevent a feared event.
When it comes to assessing obsessions,
here are the things you need to consider.
Is the obsession intrusive and repetitive?
Is it thoughts and images?
Are there dysfunctional beliefs?
Things like an inflated
sense of responsibility
and the tendency to
overestimate that threat.
Perfectionism and the
intolerance of uncertainty
or overvaluing the importance
of one’s thoughts.
And is somebody avoiding
people, places or things
because they may trigger
In doing your assessment, it’s
important to note that compulsions
are not always connected in a
realistic way to the feared event,
and they also are clearly excessive,
so they’re really overboard.
In our example of Jane, she counts
and switches lights compulsively.
This would not directly relate to
preventing an intractable illness,
which she is greatly afraid of.
So again, there is no realistic
connection between the two.
In your assessment of compulsions,
consider the following.
Are there repetitive behaviors?
Things like washing,
switching, checking things
or mental acts like counting,
repeating words and phrases.
Does the individual feel driven
to perform a compulsive act
in response to an obsession or according to
rules that must be very rigidly applied?
In compulsions, the aim
is to reduce the stress
triggered by obsessions or
prevent a feared event.
Think about our example with
Jane, she washed her hands
and counted in an effort
to avoid becoming ill.
And when somebody has a compulsion,
they will avoid people, places or
things that trigger the compulsive act.
Also note that if it is embarrassing,
then a patient may not volunteer
information or it may incriminate them
such as thoughts of wanting
to harm other people.
So when you’re doing your assessment
and you’re overtly asking somebody
about obsessions and compulsions,
it's really important to note that
they might feel embarrassed
by sharing this information.
So therefore, that
therapeutic alliance between
the doctor and patient
is extremely important.
You must have their trust in
order for them to open up.
The OCD is also associated with
a number of different things.
It’s associated with
reduced quality of life
as well as high levels of social
and occupational impairment.
So when you’re doing your assessment of
a patient you suspect might have OCD,
what are some questions
you should ask?
So we could start with these.
How much time is spent obsessing
or engaging in a compulsive act?
How much has independence
So for example, can an individual
no longer leave their home
because of their obsessions
Have they lost their jobs?
Lost ability to run errands?
That kind of thing.
Also, what places, people or
situations are being avoided?
Ask how has the
family been impacted?
It’s really important to note if there
are imposed rules onto the family,
not only the individual
suffering with OCD,
but are they instructing their family that
certain people can and can’t visit the home.
Are they very rigid about where things
are placed and put away within that home
and to the point that
it’s causing problems.
Ask how timely homework or
occupational work is getting done?
And how often does one see the physician?
So, you want to make sure
that you ask whether or not
your patient is checking with
someone about their symptoms.
There are some rating scales that
can be useful in assessing OCD.
One that I’d like to review
is called the YBOCS.
It’s the Yale-Brown
Obsessive Compulsive Scale.
And this is the standard
for measuring OCD.
It consists of a checklist of
obsessions and compulsions
and a scale that will actually
rate and assess the severity.
And it’s really important
to get a baseline
and then after the patient’s
undergone treatment for their OCD,
to repeat the YBOCS.
In that way, you have a measurable tool to
see how much their symptoms have changed.
In completing the assessment, you
want to think again about obsessions
which are recurrent and persistent
thoughts, urges or images
that are experienced at some
time as unwanted and intrusive.
And they cause marked stress and anxiety.
An individual will attempt to ignore
such thoughts, urges or impulses
or neutralize them
The compulsions again are
that an individual feels driven to
perform in response to their obsessions.
Behaviors or mental acts are aimed at
preventing or reducing anxiety or distress,
although they are clearly
excessive when it comes to OCD.
So what are the different types of OCD?
There are specifiers that you can use.
For example, a lot of patients with OCD
will also experience a tic disorder.
So you could say, with or without presence
of a tic disorder as a specifier.
You also could say whether or not the
patient has good or fair insight.
This is important because
insight is going to be a tool
that will allow the patient to follow
the treatment plan and recommendations.
You can also note if there is poor
insight, which is also going to affect
the individual in how they
think about their disorder
and it will probably shift
and change overtime,
so it’s always important to recheck in
with your patients about their insight.
And another specifier for OCD is with
absent insight or delusional beliefs.
So, the individual is completely
convinced that OCD beliefs are true
with or without
Also note, insight refers to the patients
awareness that something is wrong
and this really can affect the willingness
of the patient to receive treatment.
And less compliant patient may
not have as good of an outcome
as one who actually adheres
to the treatment plan.
So what kind of treatment
should you use for OCD?
There are certainly medications
and also talk therapy options.
When it comes to treating OCD,
note that behavioral and talking
therapies should never be neglected.
They can be just as effective and sometimes
even more effective than pharmacology.
The medications that we
often use in treating OCD
include SSRI and sometimes
You can refer to another
lecture in the anxiety series
for more details about
both of these medications.
When it comes to behavioral therapy,
one treatment that is very useful is
exposure and response prevention.
This involves prolonged exposure
to the ritual-eliciting stimulus
and prevention of the
For example, the patient
might touch the dirty floor
without washing his/her hands when they
have a significant fear of contamination.
This will be a behavioral exercise teaching
the patient to sit with their anxieties
after touching something a little
bit dirty before washing their hands.
Relaxation techniques are also employed
to help patients manage their anxiety
and help so that the compulsions
become less and less intrusive
and demanding in the
Studies have shown that actually using
both behavioral therapy
and pharmacology together
can best help the patient
achieve optimal results.
That concludes our discussion of OCD,
a little bit about its background,
and treatment options.