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Running Head: OCD
Obsessive-Compulsive Disorders

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Background
Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by obsessions
and compulsions. OCD is considered as the fourth most common mental disorder (Hollander and
Stein,1997). Obsession, a major element of OCD, is characterized as persistent and repetitive
thoughts, images and impulses that are improper, unwelcome, intrusive and bringing anxiety or
distress to the individual suffering from it (APA, 1994). The thoughts are usually accompanied
by compulsions to reduce the anxiety felt. These obsessions and compulsions are severe in that
they can adversely affect the daily life of the patient, especially because these are time
consuming and make the individual suffer considerable distress. Moreover, obsessions and
compulsions can cause the person functional impairment (Wright and McLaughlin, 2001; APA,
1994). People suffering from OCD are aware that their thoughts and behaviors are unreasonable
but continue to engage in them as they feel they have no choice but to do so to relieve
themselves of anxiety.
According to the DSM-IV-TR (1994), obsessions are characterized by intrusive and
inappropriate persistent ideas, thoughts, impulses, or images, which cause distress or anxiety to
the patient. While compulsions are characterized by repetition of behaviors or mental acts that
are geared towards the reduction of anxiety or distress, rather than to obtain gratification or
pleasure.
The majority of individuals diagnosed with OCD suffer from both obsessions and
compulsion, which are often associated to each other (Wright and McLaughlin, 2001). OCD
affects both the child and his or her parents (Freeman, Garcia, Fucci, Karitani, Miller, &
Leonard, 2003). The parents of the children suffering from OCD likewise suffer from distress

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and negative parental experience due to anxiety on the condition of their child and fear of
uncertainties in the future of their children. Having a loved one suffering from OCD is indeed a
distressing experience (Storch, Lehmkuhl, Pence, Geffken, Ricketts, Storch, & Murphy, 2009).
Children suffering from OCD worry about many things. For instance, they may have the feeling
that bad things might happen to them someone they love, or they may have a feeling that they
constantly need to get things right and will frequently need to check to make sure. These
obsessive worries keep ringing in their head and prevent them from focusing on other things. The
large challenge to interventionists is the accompanying anxiety component (Piacentini, Bergman,
Keller, & McCracken, 2003).
Children having bad thoughts suffer greatly because they are not aware of their source,
which leads to confusion as to what they are going to do with those thoughts or images. Many
are unable to confide in their parents due to the violent nature of these thoughts, especially if
they involve hurting their parents. This leads to the child being irritable, withdrawn, having
difficulties in focusing in his or her academics and school activities and having a propensity
toward avoiding people, things and going to certain places. (Piacentini et al, 2003). If an
individual has OCD, he or she has an increased risk to develop other psychiatric disorders
(Geller, 2006).
There is no concrete incident rate of OCD because there are still many children or people
who refuse to divulge that they are suffering from such disorder or it is also a possibility that
they do not know yet that they are suffering from it. Hence, they fail to subject themselves to
treatments or interventions (Wright and McLaughlin, 2001). Various estimations of incidence
rate have been identified and given by different institutions and researchers. According to Zohar
(1999), OCD affects 1% to 3% of the general population before reaching adulthood. According

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to Geller, Biederman, Jones, Shapiro, Schwartz, & Park (1998), an estimate of 2% to 4% of
individuals are likely to develop OCD before they reach the age of 18 years. March and Leonard
(1996) report that 1 in 200 children and adolescents are suffering from OCD.
Symptoms
The following are the symptoms of the Obsessive Compulsive Disorder according to
DSM-IV-TR (1994):
1) Obsessions – Obsessions have the following definition (a) pervasive and repetitive
thoughts, images or impulses that are intrusive and improper and cause marked distress
and anxiety; (b) such thoughts, images or impulses are not mere extreme worries about
real-life conditions; (c) the sufferer exerts efforts to suppress or ignore these unwanted
thoughts, impulses or images of even just to neutralize them through some action or
thought; and (d) such person knows that the unwanted thoughts, images or impulses are
from his or her own mind and not just inserted into his or her mind.
2) Compulsions – Compulsions are defined as (a) repetitive behaviors such as washing of
hands, ordering and checking or mental acts like counting, praying or uttering words
silently in a repetitive manner. The person suffering from it feels that he or she is obliged
to do them as response to an obsession or because of the rules that should be religiously
performed; and (b) the behaviors or mental acts are meant to prevent or reduce the
distress felt or prevent some avoided situation or condition. However, such behaviors or
mental acts are not in accordance with what they should be neutralizing or are evidently
extreme or excessive.

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3) There may be some point that the person suffering from it will recognize that the
obsessions or compulsions are already unreasonable or excessive. However, this is not
the case for children.
4) The obsessions or compulsions bring marked distress or consume excess amount of time
(e.g more than 1 hour in day), or considerably obstruct the normal activity and routing of
a person, his or her occupation or education or even relationships.
5) The presence of another disorder from the Axis I increases the risk of symptoms not
limited to obsessions or compulsions.
6) The disorder is not due directly from the psychological effects of a substance like drugs
or medication nor it is a general medical condition (American Psychiatric Association
2000)
Because of the OCD, individuals may suffer from repetitive rituals like hoarding, hand
washing, counting, tapping of the foot, checking doors and locks and may have an unreasonable
fear of being contaminated or causing harm to others (March & Leonard, 1996).
OCD is difficult to recognize because patients do not share the same exact symptoms. A
patient may show changes in symptoms as time passes by which are not caused necessarily by
changes in their environments. There a too few children who are likely to show only one type of
obsession or compulsion because most children suffering from OCD show different symptoms
for both types (March and Leonard, 1996). The symptoms of OCD may be overlooked when a
patient is also suffering from other persistent psychotic symptoms because obsessions and
compulsions can also be seen from other psychotic disorders. Thus, the symptoms of OCD must
be purposely looked into for patients suffering from psychosis (Ganesan, Kumar, & Khanna,

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2001). There is also some confusion regarding the line that separates superstition or habit from
obsession or compulsion. It is said that it is normal and healthy for children to develop some
degree of superstitions, rituals and anxiety. Normally, a distinction can be made when these
superstitions or habits are developed when they have no actual purpose for it or if it obstructs the
normal functioning of a person (Wright and McLaughlin, 2001).
According to Rachman (2003), there are three types of classical obsessions, such as: (a)
aggression or thoughts of harming people; (b) sexual obsessions; and (c) blasphemous obsessions
or fears of sacrilegious actions against the church. Common obsessions also comprise of fear of
being contaminated, forbidden thoughts, urges for symmetry and a necessity to tell or confide
matters (March and Leonard, 1996). A person suffering from obsessions in harming people may
have thoughts of harming an innocent child, jumping from a high place such as a bridge,
mountain or from a tall building, leaping in the face of a train or a vehicle or may have the urge
to push another person in front of a moving vehicle or train. A person suffering from sexual
obsessions may have intrusive thoughts or images of sexual themes such as kissing, fondling,
touching, oral sex, anal sex, rape and intercourse with their friends, co-workers, strangers,
parents, children, family members or even as extreme as with animals or religious figures. These
may involve heterosexual or homosexual content with individuals regardless of age (Osgood-
Hynes, n.d.). Unlike asymptomatic people having unusual sexual images that are meaningless,
individuals suffering from OCD have unwanted sexual images and these have significant
meanings. This will make the patient feel uncertainty on whether he or she can avoid entertaining
bad thoughts which will lead to self-criticism or loathing. The patient may feel negatively critical
about himself or herself. The patient may also feel the necessity to confess as often as possible to
a religious counselor; otherwise, he or she may act out the strong sexual thoughts in an

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aggressive manner (Osgood-Hynes, n.d.). These sexual and aggressive thoughts cause severe
distress and guilt in those that experience them. They feel that their bad thoughts are equivalent
to actually acting them out. For example, just thinking about hurting someone leads to the same
level of distress as actually hurting that person. In the case of sexual and aggressive obsessions,
the person will likely engage in avoidance behavior at first. But avoiding such obsessions will
make the urge even stronger and increase the obsession and distress. Thus, to be able to lessen
the distress, the person will give in to the obsession and engage in a developed ritual. However,
this method of lessening distress only takes effect for the short term (Osgood-Hynes, n.d.).
Common compulsions are comprised of repetitive washing, checking, touching, counting,
ordering or arranging, hoarding and praying (March and Leonard, 1996)
The said unwanted intrusive thoughts (UITs) are not only suffered by persons with OCD
but are also experienced by sufferers of different disorders like those who are experiencing
depression (Clark, 2005) and schizotypal obsessions (Sobin, Blundell, Weiller, Gavigan,
Haiman, & Karayiorgou, 2000).
Interventions Aimed at Alleviating Intrusive Thoughts
Obsessive-compulsive disorder has previously been thought to be a disorder that is
untreatable or incurable(Antony, Downey, & Swinson, 1998). Currently, however, it is widely
believed that OCD is treatable primarily due to the availability of effective diagnostic assessment
techniques of OCD and modern treatments developed as a result. The most widely known
methods of treating OCD are medications (e.g. anti-depressant and Serotonin reuptake inhibitors)
and cognitive and behavior therapy (e.g. exposure, response and prevention) or can be the
combination of both (Health, n.d.). However, the treatment response can vary depending on the

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individual conditions of the patients (Ravindran, da Silva, Ravindran, & Richter, & Rector,
2009). Although such methods do not promise to cure OCD, they can control the symptoms and
will allow people to function again in a normal way (Center for Addiction and Mental Health,
n.d.).
For twenty years, cognitive behavior therapy (CBT) is the leading technique for treating
children and adults with OCD. The two key elements of cognitive behavior therapy are exposure
and response prevention (Wright and McLaughlin, 2001). The determination of the specific
symptoms of the person suffering from OCD and the factors that cause the most anxiety are the
main keys in using the CBT method. After which the specific therapies based on the identified
specific symptoms and factors can be developed that will help the patient to progressively have
strength to be in contact with the feared stimulus. Moreover, the patient can be instructed of the
different techniques that will help him or her to prevent from engaging in his or her mental
rituals (Wright and McLaughlin, 2001).
Exposure therapy includes different types. Through exposure therapy, the patient must be
able to make contact with the stimulus that produces anxiety and continue to have contact with it
until the anxiety weakens. The most common type of exposure therapy is in vivo exposure or
direct exposure wherein the patient needs to be in direct contact with the feared stimulus. The
other type of exposure therapy is the imagined exposure wherein a child needs to imagine being
in contact with the feared stimulus (Wright and McLaughlin, 2001) or the patient is instructed to
imagine controlled exposure to objects or situations that activate the obsessions that stir up
anxiety. In the process of getting used to the obsessional cue, the exposure will gradually lessen
the anxiety. This is what is called habituation (CAMH, n.d.).

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Response prevention on the other hand, deals with avoiding known rituals that are either
discernible or mental in nature (Wright and McLaughlin, 2001). The stimuli here are the rituals
that people with OCD do in order to reduce the anxiety felt (CAMH, n.d.). In this technique, the
patient needs to avoid engaging in the ritual when he or she faces the situation that would
normally make him or her engage in the ritual. The patient learns to resist the compulsion to do
his or her rituals and in the process will learn eventually to stop engaging in such unwanted
behaviors (CAMH, n.d.). The members of the family will be used to help the patient from
preventing to engage in the ritual in his or her everyday life and to give support to the patient.
(Wright and McLaughlin, 2001)
According to Abramowitz (1996), the combination of the exposure and response
prevention will enable CBT to be more effective. It has been found by Foa, Steketee, & Milby,
(1980), that the exposure method is effective in diminishing the obsessions and anxiety felt while
response prevention can aid in getting rid of the rituals. As previously noted, determining the
specific symptoms is important and CBT should focus on such symptoms. In doing so, it is
necessary to understand in detail the individual condition and situation of the patient and records
should be compiled for the future implementation of treatment programs (Wright and
McLaughlin, 2001).
The Center for Addiction and Mental Health (n.d.) relates how exposure and response
prevention work. The patient enumerates a list of situations or cues that stir up their obsessional
fears at the start of the process. Afterwards, the patient is exposed to the situations that cause
mild to moderate anxiety. The patient then habituates to the situations and eventually will work
against the situations that causes greater anxiety. The duration of the treatment hinges on the
ability of the patient to bear the anxiety and to oppose compulsive behaviors (CAMH, n.d.). The

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process of exposure is usually done with the assistance of a therapist and a session would
normally run from 45 minutes up to three hours per day (CAMH, n.d.). Direct exposure
technique (in vivo) may not be possible in some cases when done in the office of the therapist. In
such a case, the therapist would need to employ the imaginal exposure technique which is done
through exposing the patient to situations that activate obsession through imagining a variety of
scenes (CAMH, n.d.).
The objective of the exposure therapy is to have the patient stay in contact with the
situations that trigger the obsessional behaviors without performing the rituals. If the person
keeps on responding to the feared stimulus by engaging to the ritual behaviors, the person will be
asked to be exposed more in such situations until such time that the patient will be able to resist
and abstain from engaging to ritual behaviors. For homework or therapy while at home, the
patients are likewise trained to become experts in rating their own levels of anxiety to assess
their progress while undergoing the task of exposure. The patient will then be encouraged to
continue undergoing exposure and response prevention treatment once the patient shows
progress and will then be subjected to new situations as the therapy may deem fit. The treatment
usually runs between 14 and 16 weeks (Health, n.d.). And according to the Center for Addiction
and Mental Health, even patients who have been suffering from OCD for a long period can take
advantage from the exposure and response prevention treatment and the success will hinge on
different factors and the motivation of the patient (CAMH, n.d.). The Center for Addiction and
Mental Health has documented studies showing the efficiency of the said therapy that as high as
75 per cent of the patients suffering from the symptoms of OCD experienced improvements in
their conditions upon undergoing therapy. Likewise, majority of the patients that undergone
treatment for two to three years have experienced long-term improvement (Health, n.d.).

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However, patients that do not show overt compulsions are those that benefit less from the
exposure and response prevention (CAMH, n.d.)..
Cognitive therapy (CT) is also combined with the exposure and response prevention
treatment in treating a patient with OCD. A hierarchy of situations that trigger distress is created
when a person is suffering from OCD. And when the person undergoes exposure tasks, he or she
is required to pay attention specifically to thoughts and feelings related thereto (CAMH, n.d.).
The focus of CT is on how the patient takes their obsessions such as what they think about these
obsessions, his attitude toward such obsessions and why he is having such obsessions. The
understanding of this fear can be changed and challenged or re-interpreted so that the situation
will no longer be seen as a high risk activity. This may require a lot of time before the results can
be seen but the outcome may be desirable (CAMH, n.d.). CT also aids patients in identifying and
reassessing their beliefs regarding the implications of engaging or not engaging in their
compulsive behaviors and to do actions to change or extinguish such unwanted behaviors.
Challenging and confronting the situations will help control the behavior. One effective tool that
is used in CT is the thought record. It can identify, challenge and correct wrong interpretations of
the intrusive thoughts. The patients record their obsessions and the associated interpretations
they have with the obsessions in the thought record (CAMH, n.d.). When the patients are able to
learn to identify their intrusive thoughts and the interpretations they have for them, the evidence
that probably support and do not support the obsession will then be examined. Next is the
identification of the cognitive distortions in the obsessions and the development of a less
threatening and alternative response for the unwanted intrusive thoughts. The patterns will be
identified during the session with the therapist and during the direct exposure activity and the

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patient is also expected to continue recording the information on the thought record during the
sessions (CAMH, n.d.).
Suppression is also a common but lesser popular technique used for countering unwanted
thoughts (Najmia, Riemann, & Wegner, 2009). This may be due to the fact that the normal
tendency of individuals with OCD are attempting to suppress their unwanted intrusive thoughts
(UITs) as shown by a survey conducted by Freeston and Ladoucer (1997). Thus, the method of
suppression is methodically developed. However, a drawback of this method is that a person who
supresses a thought may likely have a recurrence of his or her intrusive thoughts (Wegner, 1994).
This is called the rebound effect. As stressed further by Najmia and colleagues (2009), the
repeated efforts of suppressing UIT will only worsen the existing state of obsession. Suppression
will only increase the occurrence of unwanted thoughts and the consequent distress after
suppression or the so-called rebound effect. And even if the suppression will not lead to the
rebound effect, the distress will only be worsened and will not help to ease the anxiety (Najmia,
Riemann, & Wegner, 2009).
It has been found by Wegner, Schneider, Carter, & White (1987) in their experiments that
focused distraction can be effective in getting rid of unwanted intrusive thoughts. This is against
the technique of suppression wherein Wegner et al. (1987) averred that successful suppression
can be attained by increasing the access to the distracter thoughts. This is complimented by
Salkovskis and Campbell (1994) where they asserted that distraction is more efficient in
lessening the occurrence of UITs than suppression and found to be even better in reducing
distress than neutralization (Salkovskis, Thorpe, Wahl, & Wroe, & Forrester, 2003). Focusing
distraction away from the unwanted intrusive thoughts is much the sme with focusing the
attention to something else that is not the UIT. The use of the technique of strategically

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controlling the attention and changing the focus of attention away from the negative implications
of UITs have been seen to be effective by several examinations (Najmia, Riemann, & Wegner,
2009; Wegner et al., 1987). Suppression is not as effective as employing focused distraction as
suppression will only be effective if done by focusing on a specific source of distraction (Najmia,
Riemann, & Wegner, 2009). However, unlike the positive feedbacks given to the cognitive
behavior therapy, focused distraction is found to be for temporary relief from distress and
intrusions only (Najmia, Riemann, & Wegner, 2009).
There are four steps suggested by the book Brain Lock: Free Yourself from Obsessive-
Compulsive Behavior written by the psychiatrist Jeffrey Schwartz (1996) in dealing with the
OCD. The following steps are:
1) Relabel – Be familiar with the intrusive obsessive thoughts and the that are outcomes of
OCD;
2) Reattribute – understand that the intensity and intrusiveness of the thought is by reason of
the OCD and it could be caused by a biochemical imbalance in the brain;
3) Refocus – focus attention on something else even for some minutes and do another
behavior; and
4) Revalue – do not look at OCD by its mere face value.
There are recent studies showing the effectiveness of acceptance and commitment
therapy (ACT) in treating OCD. Acceptance enables the patient to notice UITs and discourages
the patient to struggle with it (Twohig, Hayes, & Masuda, 2006). Through acceptance, the
patient is encouraged to be exposed to the UIT and is discouraged from suppressing UIT
(Najmia, Riemannb, & Wegner, 2009). This is in line with the findings in other studies regarding

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other psychological problems (i.e. mood and anxiety disorders) wherein it was proven that
acceptance has positive correlation with lesser distress as compared to expressive suppression
(Campbell-Sills, Barlow, Brown, & Hofmann, 2006).
Another research from the University of British Columbia’s Anxiety Disorder Clinic
shows that patients suffering from obsessive-compulsive disorder (OCD) reveal considerable
improvement upon undergoing therapy that points to their primary obsession (Haley, 2004). In
the beginning, there will be a detailed analysis of the obsession, its evolution and the necessary
techniques to effectively manage it. The process will be a targeted therapy intended directly at
the primary obsession concerned. The therapy involves combination of different therapy. There
will be an appraisal of the obsessions after which the necessary techniques shall be determined to
manage and minimize the impact of obsession. In short, there will be a determination of the
source of obsession and the means of managing it (Haley, 2004). Thus, there will be two stages
in the process of treatment. The first stage is the psychoeducational. This is the stage where the
patients are provided with the information on the high frequency of unwanted intrusive thoughts
within the population. The patients are likewise educated about the similarities of the content and
form of clinical and nonclinical unwanted intrusive thoughts. This is also the stage where the
patients are informed of the importance of the undergoing treatment (Haley, 2004).
The second stage refers to the cognitive behavioral treatment. The principal goal of this
stage is to eradicate the negative and wrong interpretations of the meaning and relevance of the
obsessional cognitions and to change these with reasonable alternative interpretations. Also, the
second stage aims to change the associated abnormal safety behaviors such as avoidance or
escaping the situations that bring about obsessions, covering up of the obsessions from other

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people, wrong efforts of neutralization, or suppression of the unwanted thoughts which will
likely sustain the obsessions (Rachman, 2003).
Lynne Siqueland, (2009) reminded the parents of the children suffering from OCD
(especially those suffering from bad thoughts) that such disorder is very treatable despite. There
are already numerous techniques that surfaced that can be used for every form of OCD. That is
why it is very important to have a careful assement done by a competent professional who has a
vast experience in treating OCD especially that the symptoms of OCD can be confused with
other psychological disorders.
1) Assessment stage
At the start of the treatment, kids may feel stress and could be upset in filling their heads
about the unwanted thoughts and could even feel suicidal at the moment. According to
Siqueland, it is important to determine the distinction between kids who have OCD and do not
have OCD. The bad or violent thoughts of kids with OCD have them as commands as outside
voice and not from their heads. Kids may enjoy or like having such thoughts. On the other hand,
kids with OCD feel very distress in having bad thoughts and would exert effort to avoid them.
Normally, a child having abnormal thoughts may be said to be suffering from OCD if the
thoughts are contrary to the personality of the child. The child in this case will show great
amount of distress about having intrusive thoughts and would try to avoid them. And in response
to these intrusive thoughts, a child may develop doing rituals such as praying, confessing, or
uttering special or unusual words (Siqueland, 2009).
2) Education stage

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The most vital part in treating OCD is educating the child and family as to what is going
on within the brain of a child: that kids are having nonsense messages within their heads that
appear to be very scary. It is likewise important to make the child understand that it is his
reaction or response to the intrusive though that is igniting the problem. And the most important
thing to do is to have the disorder renamed as OCD or anything else. It is also crucial to let the
kids understand that they are no longer engaging to do what their thoughts demand no matter
how much it bothers them; that it will neither help if they just try to suppress the thoughts as they
will just occur more often (Siqueland, 2009).
Kids with OCD need to be taught to let the thoughts pass their heads like any other
thoughts; that it is not necessary to stop them and force them out; that just having the thoughts
does not mean that they want to do them (Siqueland, 2009).
3) Working on the rituals
After educating the child and the family, the next step is to work on the rituals. This is
usually done by confiding or telling all the thoughts. This process is the most painful and
disappointing part for the parents. Parents need to be composed and strong to send positive lights
to their children. Upon hearing or knowing all the thoughts of the child, the parent should avoid
reacting negatively about their kids especially if the thoughts are too abnormal or violent. In this
process, the therapists shall work closely with the kids and parents to reduce the rituals
gradually. This can be done by using coupons to let kids write and confess their thoughts on it.
The asking of questions by the therapist should be done in a very careful manner (Siqueland,
2009).

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If there is fear in being near to a pair of scissors because he or she might stab his or her
parents, the kid needs to work on holding a pair of scissors while he is near his parents. The
practice will be done step by step until the kids will reach the most feared situations initially in
the office of the therapist then eventually at home. The kids should be informed in the process
that they are not exposed to the situations to cause them danger, but it is important for them to
get used to the feared situations as they will eventually occur in their daily life and are not indeed
dangerous to them (Siqueland, 2009).
Another method is using audiotape loops. The child in this case is required to write the
feared thoughts in detail on paper. Afterwards, the child will then be instructed to read what he
has written and it will be recorded in an audiotape. The child will then be required to listen to
the recording until the he has become “desensitized” or becomes used to the previously dreaded
message in his head or until the message becomes boring as opposed to scary. The parents, on
the other hand, need to be informed of the relevance and reason of using bizarre approaches. This
kind of technique is applied to kids ages 10 or over, and for younger children, therapists can
instead use songs having the feared content so as to expose the children but the tone in this case
should be made humorous or meaningless rather than having a serious tone (Siqueland, 2009).
If the thoughts are too depressing or overwhelming that the treatment cannot just be done
at the moment, the therapist can seek the aid of medication (e.g. SSRI, antipsychotic
medications) to eliminate the intrusive thoughts (Siqueland, 2009).
Moreover, the role of the parents and family members are vital for the success of the
therapy. The children need to know that their parents are brave and give appropriate support.
Therefore, the children will have confidence in themselves (Siqueland, 2009).

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