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OCD – notes


Spitznagel compared orbitofrontal and dorsolateral patterns of frontal lobe dysfunction implicated in subjects with OCD and schizotypy respectively, in subjects with either condition and in a mixed group with OCD and schizotypy. Results confirmed orbitofrontal type problems, such as difficulty changing cognitive set, in the OCD group only.

Cavedini[48*] on the other hand reported decision-making impaired in OCD compared to controls and panic subjects, with impairment predictive of a poorer pharmacological response for OCD. Jurado[49*] assessed memory for temporal order as well as a ‘feeling-of-doing’ judgement, finding these impaired in OCD; in a second study incidental memory for frequency was impaired in OCD.[50*]

Another interesting aspect of memory is negative priming, whereby ignoring a particular stimulus can hamper subsequent attended processing of the same stimulus. Negative priming is reduced in OCD, consistent with reduced inhibitory function. This is further explored in a study comparing schizophrenia, OCD and controls, which demonstrated differences in negative priming in OCD subtypes of checkers versus non-checkers, with differences varying with response-stimulus interval. A related tack is that of directed forgetting, based on evidence that OCD patients show impaired ability to forget negative material, with limited further support from a study comparing OCD and anxious controls.

hus Pelissier[58*] examined inductive and deductive reasoning in a small comparison of OCD, generalized anxiety disorder and non-anxious controls. OCD subjects showed differences on some tasks in probabilistic reasoning and greater conviction, echoing some of the cognitive distortions found in OCD.


Very few patients with obsessive-compulsive disorder (OCD) ever experience a complete remission of symptoms. Often a clinician stops working with the patient, or the patient stops working with the clinician, once symptoms have been reduced to tolerable levels. Although symptoms may have only reduced by a third, if the person is able to function, this may be considered “good enough.”

Treatment resistant OCD is generally defined by two adequate attempts with SRIs. SRIs stand for a class of medication called antidepressants. They include tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs). True treatment-refractory OCD can only be determined if a person has tried, at a minimum, three different SSRIs at a maximum dosage for at least 3 to 6 months each (with the TCA clomipramine being one of them). They must have also undergone behavioral therapy while on a therapeutic dose of an SSRI, and lastly, have received at least two atypical anti-psychotics as augmenters while receiving behavioral therapy and taking the SSRIs.The researchers found that the factors associated with refractoriness of OCD were more severe of symptoms, chronic course of illness, lack of a partner, being unemployed, low economic status, presence of obsessive-compulsive symptoms of sexual or religious content, and greater family accommodation of the OC symptoms. However, this was but one small study, and future studies are warranted to verify these findings.

Opiates: Researchers have postulated that the opiod system in the brain plays some role in the OCD circuitry. Several research studies indicate that opiates (like morphine) may be promising treatment for OCD alone or combined with SSRIs.

Cognitive-behavioral therapy: It is imperative that proper behavior therapy is attempted before being labeled treatment refractory. As stated, most OCD sufferers have not received an adequate trial of behavioral therapy, which is ultimately the most effective way to beat OCD long-term. While behavioral therapy and medication both have very similar results, up to 80 percent of OCD sufferers relapse when off medication.


At one time, obsessive-compulsive disorder (OCD) was thought of as a “neurotic” disorder. Sigmund Freud, the father of psychotherapy, devoted considerable attention to OCD, and believed that OCD existed on a spectrum ranging from obsessive-compulsive personality to psychosis.

His treatment of choice was psychoanalytic therapy for OCD, and this was the accepted treatment of the disorder for many decades. Because this approach was met with no success, OCD was considered a rare and intractable disorder.

People who suffer from OCD usually have at least some insight into their behaviors, making the ultimate goal of insight less useful; insight alone is not enough to “cure” OCD.

We now understand that OCD has, in large part, a biological causation (meaning, for example, that OCD behavior is not simply caused by a bad relationship with your mother), and it tends to run in families. Because of the failure of traditional psychological treatments for OCD, cognitive-behavioral treatments are now used in the treatment of the disorder, with very high rates of success.

Mild cases of OCD can be treated with self-help techniques. The book Brain Lock: Free Yourself from Obsessive Compulsive Behavior is a recommended resource for people looking for a way to combat OCD on their own.


More self-help books for OCD…

The goal of CBT is two-fold: to change thoughts and behaviors. Changes in thoughts and behaviors then lead to changes in feelings. The cognitive portion involves the identification and analysis of irrational thoughts, which are then challenged. In the behavioral portion, the therapist and client work together to change the compulsive behaviors. This typically includes techniques such as Exposure and Ritual Prevention, also called Exposure and Response Prevention (ERP or EXRP), psychoeducation (learning about OCD and how symptoms are maintained), relaxation techniques, and many others.

Exposure and Ritual Prevention is successful 80 percent of the time in significantly reducing obsessions and compulsion, making it the most effective and well-researched treatment for OCD. A person suffering from OCD feels obsessions, which cause extreme anxiety, and is then driven to perform compulsions, which momentarily relieve the anxiety. The goal of EXRP is to expose the OCD sufferer directly to their anxiety-causing obsessions, and then prevent them from performing a ritualistic compulsion to relieve the anxiety. EXRP is a hierarchical process. The therapist has the patient rank their fears from most distressing to least distressing. After the fears are ranked, the patient will then be exposed to each fear as they are ready, starting with the easiest item. The therapist does not force the client do anything the client does not want to do, so great care is taken to be sure the client is ready for the next step. The OCD patient eventually learns that the obsessions are not harmful and the anxiety diminishes on its own over time.

Because even the thought of confronting ones fears can prevent many patients from seeking CBT for OCD, many wonder if it is possible to bypass the behavioral portion of the therapy. Cognitive therapy alone can be helpful if a patient is unable to participate in the behavioral exercises, but the behavioral part of the treatment is the real key to success. Research seems to indicate that cognitive-behavioral therapy for OCD is better than cognitive therapy alone.

The therapist will typically assign daily homework and take periodic ratings of symptoms to be sure the patient is improving. The therapist will push the patient somewhat, because ultimately most people need someone to drive them at least a little for effective treatment, but not more than they can handle. It is a difficult process, but very effective and rewarding. EXRP treatment can be accomplished in seventeen 90-minutes sessions, twice per week.

CBT is also effective for most anxiety disorders and many OC spectrum disorders. Learn more about CBT for OCD…

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