Obsessive– Compulsive Disorder 475
rereading of trivial information in community newspapers and advertisement flyers was
necessary to ensure she didn’t miss some local news item that was important to her. Per-
ceived consequences and effectiveness of the compulsion may become a primary focus
in therapy since clients with poor insight often have a more difficult response to treat-
ment (e.g., Foa, Abramowitz, Franklin, & Kozak, 1999; Neziroglu, Stevens, McKay, &
Yaryura-Tobia, 2001).
Clinical Illustration of Cognitive Case Conceptualization
We can return to the case presentation at the beginning of this chapter to illustrate a
cognitive case conceptualization of OCD. Recall that Richard had long- standing mul-
tiple obsessions (1) of his hands being contaminated and passing on germs to others, (2)
that he has disgusting body odor that others can smell, (3) of abhorrent blasphemous
and sexual intrusive images that are offensive to God and will send him to hell, (4) of
doubt about the accuracy of his work, and (5) that others can see a rash on his lower
back and will be disgusted. These obsessions led to a number of compulsive rituals such
as repeated hand washing, long shower rituals, excessive checking and rechecking, rigid
daily routines, and mental compulsions. However, it was “thoughts of exposing the
unsightly red spot” that was the current primary obsession.
Assessment revealed that the body rash obsession occurred at least 25–30 times on
bad days and was associated with anxiety levels of 65–70/100. A number of situations
were identified that triggered the “body rash obsession” such as being in a public place
and sensing people behind him, feeling that his pants are loose, bending over, moving
too much in a chair, feeling itchy, and the like. Work was the most common situation
associated with the obsession in which getting up from his chair and walking in front
of others was particularly anxiety- provoking for fear that his lower back was exposed.
Moderate anxiety was the main emotion associated with the obsession. The main pri-
mary appraisals were overestimated threat (“People will see my lower back, be dis-
gusted by it, and not want to associate with me”), inflated responsibility (“I must ensure
that no one sees my lower back”), need to control (“If I don’t get rid of the obsession,
I’ll become overwhelmed by the anxiety and have to quit work”), TAF—Likelihood (“If
I think I’m exposing my back hair, I am probably exposing it to others”), importance of
thought (“The thought about my lower back must be important because it reoccurs over
and over again”), and intolerance of uncertainty (“I have to be certain that my lower
back is completely covered”).
Richard developed a number of responses to control his “lower back rash” obses-
sion. His main compulsive ritual involved repeatedly checking on whether his lower
back was exposed by pulling down his shirt or sweater. However, he also engaged in
safety behaviors such as daily applying large amounts of ointment to his lower back or
wearing loose- fitting clothing. He also relied on other neutralization strategies such as
reassuring himself that no one can see his bare back, asking his wife if his shirts were
well tucked into his pants (reassurance seeking), distracting himself with work, or just
trying to ignore the thought. He also avoided any situations associated with a high like-
lihood of lower back exposure such as beaches, pools, swimming, gymnasiums, and the
like. Richard rated the urge to engage in compulsive shirt pulling as very high (90/100)
and his level of resistance low. He perceived that his efforts to control the obsession and
its associated anxiety were moderately successful. Any failure to immediately reduce