Obsessive– Compulsive Disorder 447
of the red spot, and beliefs about the need to control the obsession and reduce
his anxiety.
In one of our sessions Richard reported an experience that provides an
excellent example of the cognitive basis of OCD. After a number of cognitive
therapy sessions, Richard wanted to begin the exposure component of treat-
ment by swimming at a public beach without a shirt. He was planning a vaca-
tion with his wife to a resort in Mexico and decided this was a great opportu-
nity to challenge his fear of exposing his lower back. Although the therapist
expressed concern that the task was too high on his fear hierarchy, Richard was
insistent that he was ready. Upon his return from vacation, Richard admitted
that he simply could not be seen in public without a shirt. His anxiety was so
intense and his fear of others’ negative evaluation so great that he avoided com-
pleting the exposure exercise. On the other hand, Richard had an intense fear
of roller coasters. While on vacation he decided to prove to himself he could
overcome his fear of roller coasters and so forced himself to take three or four
rides that resulted in a significant decline in the fear. Interestingly, he had to do
this alone because his wife was too frightened to accompany him. Why, then,
was Richard able (or willing) to challenge his fear of riding a roller coaster, a
common fear that most would consider quite rational, and yet was unable (or
unwilling) to face his fear of exposing his lower back, a highly improbable and
irrational fear? Clearly Richard’s appraisals and beliefs about the dangers of
riding a roller coaster were far more rational than his cognitive appraisals of his
obsessional concern. His attitude toward the roller coaster (i.e., “I can do this,
the worst is so unlikely”) led to successful exposure, whereas a dysfunctional
attitude (i.e., “I can’t risk this, the danger is too great and intolerable”) resulted
in continued avoidance of exposing his back.In this chapter cognitive theory and therapy is applied to the problem of OCD. We
begin with a brief consideration of definitions, diagnostic criteria, and other descriptive
information about the disorder. This is followed by a discussion of the core cognitive
features of OCD and a review of the empirical support for the cognitive model of OCD.
The third section of the chapter reviews assessment of obsessions and compulsions as
well as development of a cognitive case formulation. A description of cognitive therapy
for OCD is then discussed, with a review of treatment efficacy and areas of future direc-
tion concluding the chapter.
DiagnostiC ConsiDerationsOCD is an anxiety disorder in which the main features are the repeated occurrence of
obsessions and/or compulsions of sufficient severity that they are time- consuming (>
1 hour per day) and/or cause marked distress or functional impairment (DSM-IV-TR;
APA, 2000). Although diagnostic criteria for OCD can be met by the presence of obses-
sions or compulsions, the vast majority of individuals with OCD (75–91%) have both
obsessions and compulsions (Akhtar et al., 1975; Foa & Kozak, 1995). There is a strong
functional relationship between these two phenomena, with obsessions normally associ-
ated with a significant elevation in anxiety, distress, or guilt, followed by a compulsion
that is intended to reduce or eliminate the anxiety or discomfort caused by the obsession
(D. A. Clark, 2004).