Cognitive Therapy of Anxiety Disorders

Obsessive– Compulsive Disorder 455

idea or even a delusion, treatment response may be particularly poor (see Veale, 2007).
Finally, noncompliance, failure to complete homework and, to a lesser extent, quality
of the therapeutic relationship will have some influence on treatment response (D. A.
Clark, 2006a; Franklin et al., 2005).

Clinician Guideline 11.5

Evaluation of treatment readiness and degree of insight into the excessive or irrational nature

of the obsessional fear should be included in any assessment of OCD. Ambivalence toward

treatment or presence of overvalued ideation should lead to a reconsideration of treatment

options.

Cognitive moDel of oCD

Overview of the Model

According to the cognitive perspective, the presence of dysfunctional schemas and faulty
appraisals are critical processes in the etiology and persistence of obsessions and com-
pulsions. A cognitive model of OCD can be understood within the framework of our
generic model of anxiety presented in Chapter 2 (see Figure 2.1). Although variations
on the cognitive- behavioral model of OCD have been proposed that emphasize different
types of schemas and appraisals, they all adhere to certain basic propositions. Figure
11.1 illustrates the common elements of the CBT approach to OCD.
In cognitive appraisal models obsessions are derived from unwanted thoughts,
images, or impulses that intrude into the stream of consciousness against one’s will and
often involve content that is personally unacceptable, distressing, and uncharacteristic of
the individual. These thoughts or images often involve the same themes of dirt/contami-
nation, doubt, sex, aggression, injury, or religion that are common in clinical obsessions

Triggering

Stimulus

Unwanted

Mental

Intrusion

Salience/

Frequency

Neutralization

and

Compulsions

Faulty

Appraisals

and Beliefs

Anxiety/

Perceived

Control

figure 11.1. The cognitive-behavioral appraisal model of obsessive–compulsive disorder. From D.
A. Clark (2004, p. 90). Copyright 2004 by The Guilford Press. Reprinted by permission.