Jonathan S. Abramowitz - Understanding and Treating Obsessive-Compulsive Disorder. A Cognitive Behavioral Approach (2005)

Understanding and Treating
Obsessive-Compulsive Disorder
A Cognitive-Behavioral Approach
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Understanding and Treating
Obsessive-Compulsive Disorder
A Cognitive-Behavioral Approach
Jonathan S. Abramowitz
Mayo Clinic
LAWRENCE ERLBAUM ASSOCIATES, PUBLISHERS

2006 Mahwah, New Jersey London
This edition published in the Taylor & Francis e-Library, 2008.
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Copyright © 2006 by Mayo Foundation for Medical Education and

Research.
All rights reserved. No part of this book may be reproduced in any
form, by photostat, microform, retrieval system, or any other
means, without prior written permission of the publisher.
Lawrence Erlbaum Associates, Inc., Publishers

10 Industrial Avenue
Mahwah, New Jersey 07430
www.erlbaum.com
Library of Congress Cataloging-in-Publication Data
Abramowitz, Jonathan S.
Understanding and treating obsessive-compulsive disorder :
a cognitive behavioral approach / Jonathan S. Abramowitz.
p. cm.
Includes bibliographical references and index.
ISBN 0-8058-5184-4 (alk. paper)
1. Obsessive-compulsive disorder. 2. Obsessive-compulsive
disorder—Treatment. 3. Cognitive therapy. I. Title.
RC533.A27 2005
616.85'22706—dc22 2005041406
CIP
ISBN 1-4106-1571-5 Master e-book ISBN

To my dearest Stacy,
and our wonderful children—Emily and Miriam.
To the memory of my grandparents:

Morris Abramowitz and Dorothy Gerber—I know they would be proud.
And to their surviving spouses: Robert Gerber and Mildred Abramowitz.
Contents
About the Author ix
Preface xi
I: WHAT WE KNOW ABOUT OCD
1 Recognition and Diagnosis of OCD 3
2 Differential Diagnosis: What Is OCD and What Is Not? 37
3 What Causes OCD? 54
4 The Maintenance of Obsessions and Compulsions 75
5 Overview of Cognitive-Behavioral Therapy for OCD 92
II: HOW TO CONDUCT CONSULTATION

AND TREATMENT FOR OCD
6 Consultation I: Diagnosis and Assessment 121
7 Consultation II: Recommending a Treatment Strategy 143
vii
viii CONTENTS
8 Information Gathering and Case Formulation 163
9 Cognitive Therapy: Education and Encouragement 190
10 Treatment Planning I: Rationale and Hierarchy Development 225
11 Treatment Planning II: Response Prevention, Support, 253

and Clarification of the Plan
12 Conducting Exposure Therapy Sessions 273
13 Wrapping Up and Following Up 309
14 Addressing Obstacles in Treatment 322
Appendix A. OCD Treatment History Form for Assessing 335

the Adequacy of Previous Cognitive-Behavioral
Therapy Trials
Appendix B: The OCD Section of the Mini International 338

Neuropsychiatric Interview (MINI)
Appendix C: Yale–Brown Obsessive Compulsive Scale 340

Symptom Checklist and Severity Scale
Appendix D: The Brown Assessment of Beliefs Scale 345
Appendix E: The Obsessive-Compulsive Inventory– 348

Revised Version (OCI–R)
Appendix F: The Obsessive Beliefs Questionnaire 350

and Interpretation of Intrusions Inventory
Appendix G: Interview on Neutralization 356
References 358
Author Index 379
Subject Index 386

About the Author
Jonathan S. Abramowitz, PhD, is an Associate Professor of Psychology at

the Mayo Clinic College of Medicine and Consultant (Staff Psychologist) in
the Mayo Clinic Department of Psychiatry and Psychology, where he has
worked since 2000. He is a recognized expert on the treatment of obses-
sive–compulsive disorder (OCD) and serves as Director of the OCD/Anxi-
ety Disorders Treatment and Research Program at Mayo. Dr. Abramowitz
conducts research on the psychopathology and treatment of OCD and other
anxiety disorders and has authored more than 50 research articles and book
chapters on these topics. He regularly presents papers and workshops at re-
gional, national, and international professional conferences, and served on
the DSM–IV–TR Anxiety Disorders Work Group. Dr. Abramowitz was
awarded a Diplomate in Behavioral Psychology by the American Board of
Professional Psychology in 2003. He is a member of the Obsessive Compul-
sive Foundation’s Scientific Advisory Board, a member of the Anxiety Disor-
ders Association of America’s Clinical Advisory Board, and also serves on
the editorial boards of several professional journals. In 2003, Dr. Abramowitz
received the Outstanding Contributions to Research Award from the Mayo
Clinic Department of Psychiatry and Psychology. In 2004, he received the
David Shakow Early Career Award for Outstanding Contributions to Clini-
cal Psychology from Division 12 (Clinical Psychology) of the American Psy-
chological Association. He lives in Rochester, Minnesota, with his wife Stacy,
and daughters Emily and Miriam.
ix
Preface
Obsessive–compulsive disorder (OCD) has captured the attention of

authors for more than a century. The seemingly bizarre thoughts and
senseless repetitive behaviors featured in this disorder were refractory to
unscientific psychoanalytic and psychodynamic therapies, leading to the
view that it was an unmanageable condition. However, beginning with
Solomon’s work on animal models of avoidance learning in the 1950s, and
Rachman and colleagues’ eloquent studies on the phenomenology of
OCD in the 1970s, we have seen the development and refinement of scien-
tifically based behavioral models of OCD. This approach has led to the de-
velopment of treatment procedures, namely exposure and response
prevention, that are highly effective for reducing overt compulsive behav-
iors such as checking, washing, and other repetitive behaviors. Thus, in
the last few decades, the prognosis for the 2% to 3% of the population suf-
fering with OCD has dramatically improved.
The focus of this book reflects an even more recent transformation in the
ethos of understanding obsessions and compulsions. Clinical and research
interest has broadened from an exclusive emphasis on overt behavior to an
increased appreciation for the role of cognition in the development and
maintenance of these symptoms. In parallel fashion, a shift in focus from
overt compulsive behaviors to covert symptoms, such as obsessions and
mental rituals, has occurred. For example, we now know that most people
with OCD deploy mental, as well as behavioral, strategies (not all of which
xi
xii PREFACE
are “compulsive”) in response to obsessional fear. Studies also demonstrate

that it is these “neutralizing” or “safety-seeking” responses which main-
tain obsessional preoccupation. Most importantly, from this research has
sprung forth promising new approaches to treating OCD that rely on both
traditional behavioral and novel cognitive approaches.
I have written this book for the mental health care provider who wishes
to engage in the challenging yet rewarding pursuit of helping individuals
with OCD overcome their disorder. The aim of the first part of the book is to
present a scientifically based theoretical framework for understanding ob-
sessions, compulsions, and related phenomena. The opening chapters help
the clinician form a conceptualization of OCD that will guide the use of
treatment procedures described in Part II. Chapter 1 covers the nature of
obsessions and compulsions, and chapter 2 covers how to distinguish OCD
from other similar disorders. In chapter 3, I critically examine various ex-
planations of the causes of OCD, and in chapter 4, I outline a cognitive-be-
havioral model of the maintenance of OCD symptoms. Part I concludes
with chapter 5, which presents a description and literature review concern-
ing the two mainstream treatments for OCD: cognitive-behavioral therapy
and serotonergic medication.
Within Part II, chapters 6 and 7 outline the procedures for providing as-
sessment and consultation for OCD. Chapter 6 describes the initial assess-
ment using interview and self-report questionnaire techniques, and
chapter 7 aims to help clinicians offer the patient a proper recommendation
and rationale for treatment. Chapter 8 describes how to begin preparing for
cognitive-behavioral treatment by gathering information about the patient
in a way that will guide the construction of an individualized case formula-
tion and treatment plan. Chapters 9 through 12 constitute a manual for de-
signing and implementing empirically supported cognitive and behavioral
treatment procedures that are based on the conceptualization of OCD pre-
sented in the first part of the book. Treatment involves data collection at
various stages and has an integrated educational component. Chapter 13
describes a follow-up and maintenance program to be implemented fol-
lowing the termination of treatment. Finally, in chapter 14, I discuss how to
troubleshoot problems and complications that can arise in implementing
the outlined treatment procedures. I have incorporated case examples
throughout the book to illustrate phenomenology, assessment, and treat-
ment (of course, the names of patients have been changed to protect confi-
dentiality). Worksheets and handouts to be used in therapy are also
provided in several of the chapters.
Finally, let me offer some words pertaining to treatment manuals in gen-
eral, and manuals for the treatment of OCD in particular. An important aim
of treatment manuals is to encourage the standardization of empirically
based therapy procedures across clinicians and patients. Optimally, manu-
PREFACE xiii
als should delineate the essential principles of assessment and treatment

and provide the clinician with procedural guidelines for their implementa-
tion. The challenge in developing such a manual is to specify abstract prin-
ciples of treatment with enough detail that they can be applied to a variety
of patients, but not in so much detail that the manual becomes unwieldy
and cumbersome. Striking this balance is never more relevant than in the
case of OCD because the phenomenology of this disorder is exceptionally
heterogeneous and patient specific. Indeed no treatment manual could ad-
equately address the implementation of cognitive and behavioral treat-
ment procedures across the countless personal variations of OCD
symptoms. Therefore, my solution in this book is to present reasonably
standardized guidelines for case formulation and treatment for a number
of common OCD presentations, noting the need for ongoing assessment,
flexibility, and creativity in dealing with the more idiosyncratic symptom
variations likely to be encountered in clinical practice. For the most part,
unanticipated obstacles can be managed by falling back on the cognitive
and behavioral principles (i.e., functional analysis) that form the basis of
successful cognitive-behavioral therapy.
Acknowledgments
This book reflects how I understand, provide consultation for, and treat the
problem of OCD. The conceptual model and intervention strategies are
based on a firm foundation of scientific literature to which I am a contribu-
tor and of which I am a student. First, I wish to thank all of those who have
helped me learn from and add to this knowledge: countless patients I have
evaluated and treated, therapists I have supervised, and many wonderful
teachers who have been instrumental in my growth and learning. Kathleen
Harring, my undergraduate advisor at Muhlenberg College in Allentown,
Pennsylvania, and T. Joel Wade, my master’s thesis advisor at Bucknell
University in Lewisburg, Pennsylvania, initiated my interest in psycholog-
ical research and helped me understand the importance of science in the
field of psychology. Arthur Houts, my PhD advisor at the University of
Memphis in Tennessee, taught me to apply scientific principles to concep-
tualizing and treating psychological disorders.
While I was an intern and postdoctoral fellow at the Center for Treat-
ment and Study of Anxiety, in Philadelphia, Pennsylvania, Michael Kozak
and Martin Franklin stood out among numerous accomplished colleagues
as being particularly generous with their time and expertise. They have
helped me cultivate my professional career and I thank them for their con-
tinued insights and support through thick and thin. I hope they will see
their influence in this book because they have had a profound impact on my
work. Although I have not worked personally with Jack Rachman or Paul
xv
xvi ACKNOWLEDGMENTS
Salkovskis, their elegant writings have also had a major bearing on my

thinking and clinical work with OCD, and their conceptual models are the
centerpiece of this book and my work as a clinical scientist.
I am enormously fortunate to have so many collaborative relationships
with fine researchers and clinicians in the field of OCD and anxiety disor-
ders. I would especially like to thank David Tolin, Brett Deacon, Sarah
Kalsy, Katherine Moore, Kristi Dahlman, and Stephen Whiteside, who
have assisted me in various ways with this book, including lending case
examples, providing editorial suggestions, and helping me refine my
thinking about the concepts and treatment techniques that are covered.
Thanks also to Shawna Stussy and Marcia Redalen, whose clerical sup-
port was invaluable to this project. Finally, I wish to acknowledge Susan
Milmoe and Marianna Vertullo from Lawrence Erlbaum Associates for
their enthusiastic support and assistance throughout the writing process.
On a personal note, I am grateful for a wonderful family that gives me the
inspiration for everything I accomplish. When I began writing this book, I
was lucky enough (at the age of 34) to have all four of my grandparents still
living. However, I lost two of them—Morris Abramowitz and Dorothy
Gerber—during the year it took to complete this undertaking. This book is
dedicated to their beloved memories and to their spouses, Mildred
Abramowitz and Robert Gerber, who remain a lively force in our family. My
parents, Leslie and Ferne Abramowitz, and my siblings Andrew
Abramowitz and Michelle Clay have always been there for me with uncon-
ditional love and encouragement, even across the miles. Most of all, I am
thankful for Stacy—my adoring wife and best friend—and for our wonder-
ful little girls Emily and Miriam, who have all been so very patient with me
while I labored over this project. I hope you are as proud of me as I am of you.
I
What We Know About OCD
1
Recognition
and Diagnosis of OCD
Few emotional disorders are as devastating as obsessive–compulsive dis-

order (OCD). Patients often have difficulty with work or school, falter in
maintaining social and emotional relationships, and struggle with daily life
events that others take for granted. Moreover, the psychopathology is
among the most complex of the emotional disorders. Sufferers undertake a
measureless struggle against seemingly ubiquitous opponents: recurrent
thoughts, images, impulses, and doubts that although senseless on the one
hand, are perceived as danger signs on the other. If such thoughts cannot be
avoided or suppressed, if they cannot be resisted or rationalized, individu-
als with OCD turn to superstitious behavior in an attempt to prevent being
accountable for feared disasters. The wide array and intricate associations
between behavioral and mental symptoms can perplex even the most expe-
rienced clinicians. To illustrate the elaborate and seemingly bizarre features
of OCD, consider the following case example.
Sarah was a 26-year-old graduate student who had recently become en-
gaged to marry her longtime boyfriend, Alan. At her initial assessment, Sa-
rah described “weird thoughts and worries” that she might cheat on (or
might have already cheated on) Alan, even though she had absolutely no
desire to do so and had no history of this sort of behavior. The thoughts were
continually on her mind and had become increasingly persistent and dis-
3
4 CHAPTER 1
tressing as their wedding day drew nearer. On further inquiry, Sarah re-
vealed that she also experienced recurrent unwanted thoughts and images
of hurting innocent people. For example, while shopping for silverware for
her new house, Sarah became worried she might use her new knives to stab
people. After babysitting for her 1-year-old niece, she had intrusive distress-
ing thoughts that perhaps she had done something terrible to hurt this baby,
such as feeding her poison. Sarah had always considered herself a very kind
and gentle individual—someone others sought out for advice. She had no
legal history of any kind, which made the occurrence of these terrible
thoughts even more bewildering.
Indeed, Sarah felt very guilty for thinking these thoughts. She had begun
locking the kitchen drawers where her knives were kept and avoiding small
children. She had also started taking certain precautions out of the fear that
she might cheat on her fiancé. For instance, she tried to avoid going out alone
so that she would not impulsively “hook up” with strange men. She also kept
a written log of all her activities from the time she woke up to the time she
went to sleep. This entailed recording where she was, whom she was with,
and what she was doing every 5 minutes throughout the day. Thus, whenever
the doubts arose, Sarah could verify to herself that she had not cheated or
committed violent acts. Only when she was with Alan or other close friends
did she not feel the need to keep the log. Still, she spent excessive time trying
to analyze her thoughts and recall whether she had cheated or acted violently.
In addition, when experiencing the unpleasant thoughts and doubts, Sarah
often asked her friends if they had heard any rumors about her cheating on
Alan. She also watched the news to make sure there were no stories about ran-
dom violence. Needless to say, these symptoms were interfering with Sarah’s
ability to concentrate in school, interact socially, and enjoy her leisure time.
Alan was becoming frustrated with Sarah’s attempts to seek reassurance that
she had not cheated. At the time of her assessment, Sarah estimated that the
unwanted thoughts occupied about 8 hours each day.
Sarah’s obsessions and compulsions seem like extraordinary phenom-

ena—ideas, images, doubts, and urges that are completely contrary to her
benevolent history, future intentions, and personal moral integrity. Yet they
recur despite her ongoing efforts to control, suppress, or avoid them. There
are also bizarre, wasteful, repetitive behaviors that she acknowledges are
senseless yet cannot resist performing. Certainly these rare and illogical
symptoms are far removed from normal human experiences. Surely some
gross abnormality, in one form or another, is responsible for producing the
symptoms of OCD. Yet research findings suggest otherwise. To date there is
actually little compelling evidence that OCD symptoms are caused by ab-
normal brain structures or functions (Craske, 2003). Whereas all of our be-
haviors and thoughts (including one’s general vulnerability to anxiety)
could be reduced to genetics, convincing evidence of specific genetic anom-
alies linked to OCD is lacking (Pato, Pato, & Pauls, 2002).
Instead, research suggests OCD symptoms occur on a continuum that
includes mild obsessions and compulsions in the population at large. A
seminal study by Rachman and de Silva (1978) found that 80% of a non-
RECOGNITION AND DIAGNOSIS OF OCD 5
patient sample reported occasional intrusive unwanted thoughts, the con-

tent of which was identical to obsessions reported by a group of OCD
patients such as Sarah. Examples of “normal obsessions” among non-
patients included thoughts of harming one’s family, ideas about unaccept-
able sexual behavior, impulses to harm babies and the elderly, and thoughts
about germs. Whereas both OCD sufferers and nonpatients may describe
their intrusions as distressing, clinical obsessions are of greater frequency,
intensity, and duration, and they evoke greater distress and more resistance
compared to everyday obsessions. Other studies of nonpatients
(Ladouceur et al., 2000; Muris, Merckelbach, & Clavan, 1997) have demon-
strated that most people engage in various strategies to deal with or resist
unwanted intrusive thoughts; these strategies are remarkably similar to
compulsive behaviors observed among people with OCD. Examples in-
clude superstitious behavior, rationalizing or analyzing, checking, reassur-
ance seeking, and thought suppression. These studies provide convincing
evidence that people with and without OCD differ quantitatively, but not
qualitatively, in their experiences.
But what causes clinical OCD symptoms? That is, how do normal intru-
sive thoughts and compulsive behavior progress into the more bizarre, dis-
tressing, and uncontrollable symptoms that we call OCD? If OCD
symptoms are illogical, why do sufferers not recognize this and change
their behavior? I address these important questions in the first part of this
book by discussing current clinical and research findings that relate to cog-
nitive and behavioral aspects of obsessions and compulsions. Progress in
understanding the development and persistence of clinical obsessional
problems from a cognitive-behavioral perspective has enhanced ap-
proaches to conceptualizing, assessing, and treating OCD. The second part
of the book illustrates how to use cognitive and behavioral assessment and
treatment techniques that are based on the conceptual model presented in
Part I to successfully reduce clinical obsessions and compulsions.
OCD ACCORDING TO THE DSM–IV
According to the Diagnostic and Statistical Manual of Mental Disorders (4th

ed., text revision [DSM–IV–TR]; American Psychiatric Association, 2000),
OCD is an anxiety disorder defined by the presence of obsessions or com-
pulsions that produce significant distress and cause noticeable interfer-
ence with various aspects of functioning such as academic, occupational,
social, leisure, or family settings. Table 1.1 presents a summary of the
DSM–IV criteria for OCD. Obsessions are defined as intrusive thoughts,
ideas, images, impulses, or doubts that the person experiences in some
way as senseless and that evoke affective distress (i.e., anxiety, doubt).
Classic examples include preoccupation with contamination, doubts
TABLE 1.1
DSM–IVDiagnostic Criteria for OCD
A. Either obsessions or compulsions.

Obsessions are defined by (1), (2), (3), and (4):
(1) Repetitive and persistent thoughts, images or impulses that are
experienced, at some point, as intrusive and inappropriate and
that cause marked anxiety or distress.
(2) The thoughts, images, or impulses are not worries about real-life
problems.
(3) The person tries to ignore or suppress the thoughts, images, or im-
pulses, or neutralize them with some other thought or action.
(4) The thoughts, images, or impulses are recognized as a product of
one’s own mind and not imposed from without.
Compulsions are defined as (1) and (2):
(1) Repetitive behaviors or mental acts that one feels driven to per-
form in response to an obsession or according to certain rules.
(2) The behaviors or mental acts are aimed at preventing or reducing
distress or preventing feared consequences; however the behaviors
or mental acts are clearly excessive or are not connected in a realis-
tic way with what they are designed to neutralize or prevent.
B. At some point during the disorder the person has recognized that the obses-
sions or compulsions are excessive or unreasonable.
C. The obsessions or compulsions cause marked distress, are time-consuming
(take more than 1 hour a day), or significantly interfere with usual daily
functioning.
D. The content of the obsessions or compulsions is not better accounted for by
another Axis I disorder, if present (e.g., concern with appearance in the pres-
ence of body dysmorphic disorder, or preoccupation with having a serious
illness in the presence of hypochondriasis).
E. Symptoms are not due to the direct physiological effects of a substance or a
general medical condition.
Specify if:
With poor insight: If for most of the time the person does not rec-
ognize that his or her obsessions and compulsions are excessive or
unreasonable.
Note. Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision), by American
Psychiatric Association, 2000, Washington, DC: Author. Copyright 2000 by the American
Psychiatric Association. Adapted with permission.
6
about making terrible mistakes, and unwanted sexual and violent im-
pulses. Compulsions are urges to perform behavioral (e.g., checking, wash-
ing) or mental rituals (e.g., praying) in response to obsessions. It is
important to keep in mind that compulsive rituals are performed deliber-
ately and in response to a sense of pressure to act. Compulsive behavior is
usually perceived as senseless or excessive.
The DSM–IV definition implies that obsessions and compulsions are in-
dependent phenomena in that one or the other is necessary and sufficient
for a diagnosis of OCD; yet this issue has been a matter of debate. To ad-
dress this question, a large multisite field study of OCD patients was con-
ducted during the early 1990s (Foa & Kozak, 1995). Among the 411 field
study participants, 96% reported both obsessions and compulsions on the
symptom checklist of the Yale–Brown Obsessive Compulsive Scale
(Y–BOCS–SC; Goodman, Price, Rasmussen, Mazure, Delgado, et al., 1989;
Goodman, Price, Rasmussen, Mazure, Fleischmann, et al. 1989; see chap. 6),
only 2.1% reported predominantly obsessions, and only 1.7% reported pre-
dominantly compulsions. Moreover, of those who reported both symp-
toms, 84% indicated that they performed compulsive rituals to either
reduce the likelihood of harm or to reduce subjective distress in general.
These data suggest that the overwhelming majority of OCD patients have
both obsessions and compulsions, and that for the most part, compulsions
are performed deliberately with the aim of reducing obsessional distress.
Further support for the idea that obsessions and compulsions are closely
related in a functional manner comes via a number of studies that have
identified symptom dimensions and subtypes of OCD. These investiga-
tions consistently find that specific types of obsessions and compulsions
load together on the same symptom-based factors and clusters (e.g., con-
tamination obsessions with washing rituals; e.g., Abramowitz, Franklin,
Schwartz, & Furr, 2003; Leckman et al., 1997; Summerfeldt, Richter, Antony,
& Swinson, 1999) as well as on measures of symptom severity (e.g., Deacon
& Abramowitz, 2005b). Moreover, there is evidence that the persistence of
obsessional preoccupations is linked to the repeated performance of com-
pulsive behavior (discussed further in chap. 4). So, as much as the distinc-
tion between obsessions and compulsions is intuitively appealing, the
clinician should consider that OCD phenomenology does not necessarily
distill neatly into these two categories.
The DSM’s emphasis on the repetitiveness and persistent nature of obses-
sions and compulsions falls short of helping the clinician fully understand
the essential nature of OCD. Whereas these characteristics are the most
readily observable signs of the disorder, the defining characteristic of
OCD is actually in the functional relationship between obsessions (which
evoke distress) and efforts to reduce this distress (e.g., compulsions). In
treating individuals with OCD it is useful to view the disorder as one in
8 CHAPTER 1
which obsessional thoughts have become the focus of concern; compulsive

behavior is a means of resisting or controlling intrusive thoughts (and the
feared consequences of these thoughts). Moreover, as I discuss later, it is
now well known that compulsive rituals such as washing and checking
represent only one class of overt and covert tactics that patients use in re-
sponse to their distressing obsessional thoughts.
The balance of this chapter introduces the reader to obsessions, compul-
sions, and other phenomena present in OCD that are important in under-
standing the disorder’s complexity. Five symptom dimensions (e.g.,
contamination, harming, hoarding) that have been identified and studied
are also discussed. The overall aim here is to help the clinician develop an
approach to thinking about the symptoms of OCD that leads to the effective
assessment and delivery of cognitive-behavioral treatment.
OBSESSIONS
One of the most striking features of OCD is its heterogeneity—obsessions

present as endlessly personalized variations on a somewhat restricted
number of themes. Foa and Kozak (1995) found that over time, most pa-
tients evidence multiple types of obsessions, as well as shifts in the content
of these phenomena. In general, obsessions are experienced as unwanted,
repugnant, threatening, obscene, blasphemous, nonsensical, or all of the
above. Using a sample of 145 individuals with OCD evaluated at the Mayo
Clinic, we examined the prevalence of various obsessional themes as cate-
gorized by the Y–BOCS–SC. These findings, along with representative ex-
amples of our patients’ specific obsessions, are summarized in Table 1.2.
Aside from their thematic content, obsessions may take various forms,
including doubts, images, impulses, fears, obsessional thinking, and mis-
cellaneous forms (Akhtar, Wig, Varma, Pershad, & Verma, 1975). Descrip-
tions and examples of the various forms are presented in Table 1.3.
Characteristics of Clinical Obsessions
It might be tempting to label any kind of repetitive thought or preoccupa-

tion as an obsession. Indeed this term is used indiscriminately in everyday
language to refer to many types of repetitive thinking such as worries about
everyday circumstances, a fascination with a certain type of car, a romantic
or sexual crush, or the tendency to pay close attention to details. Each of
these forms of cognition could be described as repetitious, and some might
fall into the categories of obsessions listed in Tables 1.2 and 1.3. However, in
the clinical sense, the term obsession is reserved for a very specific type of
thinking. In fact, it is helpful for the clinician to become accustomed to rec-
ognizing obsessions less by their repetitiveness or thematic content, and
TABLE 1.2
Primary Obsessions Reported by 145 Patients With OCD
Category n % Case Example

Contamination 84 57.9 My boss has a cold sore and touched my stapler;
now I will get a cold sore.
If I touch this bottle I will never feel clean again.
I might have stepped in dog feces and then spread
some of the germs to the floor of my house.
Aggressive 82 56.6 Image of my parents in a fatal car accident.
If I don’t correct other people’s carelessness (at work in a
factory), it will be my fault if something terrible happens.
Impulse to yell curse words out loud during class.
Maybe I didn’t fully document the patient’s symp-
toms, and as a result they will not get proper care.
Other people will think I was dishonest.
Symmetry/ 62 42.8 Odd numbers are “wrong.”
Order The pictures must be evenly spaced on the wall.
Religious/ 54 37.2 Is it OK to swallow saliva on Yom Kippur (a Jewish
Morality fast day) if you are thirsty?
Unwanted image of Jesus masturbating on the cross.
Maybe I cheated on the exam without realizing it.
Somatic 49 33.8 There is something wrong with my rectal sphincter
muscle.
One of my breasts is larger than the other.
Hoarding/ 35 24.1 I need to save all of these art supplies in case the
Saving school system cuts back on spending for art classes.
If I throw away pictures of dogs it’s like I am being
disrespectful to dogs.
I might miss important information about my disorder.
Sexual 26 17.9 Urge to look in the direction of people’s genitals.
Unwanted image of my grandparents having sex.
I could be gay since I admired that man’s clothes.
Miscellaneous 60 41.4 If I say “cancer” someone in my family will get cancer.
Odd numbers cause harm.
Doubts that people don’t completely understand
what I say.
Note. Up to three primary obsessions were identified for each patient.
9
TABLE 1.3
Characteristics of the Six Forms of Obsessions
Form Characteristics Case example

Obsessional Persistent uncertainty over I may not have locked the doors,
doubts whether a task has been com- and someone could break in.
pleted, or whether one is (or I may have stepped in dog poop
may come to be) responsible without realizing it.
for harm
Was that a bump in the road or a
person that I hit with my car?
Obsessional Persistent mental visualiza- Images of loved ones seriously
images tions that are experienced as injured or dead.
troubling or distressing Unwanted images of one’s
grandparents having sex.
Images of Christ’s penis.
Obsessional Unwanted impulses or Urge to push an elderly person
impulses notions to behave in ways to the ground.
that would be inappropriate; Urge to yell obscenities in
often sexually or aggressively church.
Urge to jump in front of an
oncoming car or train.
Unwanted urge to sexually
assault someone.
Obsessional Excessive anxiety that one What if I stabbed my wife in her
fears might lose control and act sleep?
on impulses What if I drowned my infant?
Obsessional Endless pondering over Maybe a person with herpes used
thinking future negative outcomes this bathroom before I did and
now I will get herpes and spread
it to my family.
What if God didn’t appreciate
the joke I just told and now I am
damned to hell?
Pondering over whether one is a
“moral person.”
Miscellaneous Thoughts, tunes, numbers, The number 666.
obsessions and so on, that are distressing The word cancer or death.
and difficult to dismiss
10
more by their functional properties—that is, how they are triggered, how
they are experienced, and how the person responds to them.
To this end, three characteristics set clinical obsessions apart from other
repetitive cognitive phenomena. First, obsessions are experienced as un-
wanted or uncontrollable in that they typically intrude into the sufferer’s
consciousness, often at what seem to be terribly inappropriate times. Al-
though not deliberate forms of thinking, obsessions might be cued by cer-
tain situations or stimuli. For example, thoughts of screaming obscenities
might arise at the library or in a place of worship, impulses to harm a child
might be triggered by the sight of sharp objects, or the idea that one’s hands
are contaminated might surface at the sight of a garbage can or at mealtime.
At other times, obsessional thoughts intrude without identifiable environ-
mental cues. Examples include thoughts of having left the car door
unlocked and unwanted images of loved ones being injured in accidents.
The second characteristic that distinguishes obsessions from other
types of thinking is that although personally relevant, the content of ob-
sessions is incongruent with the individual’s belief system and is not the
type of thought one would expect of himself or herself (sometimes re-
ferred to as ego-dystonic). Examples include a new mother’s unwanted im-
age of drowning her infant or a religious person’s unwanted thought that
God is dead. Such thoughts that directly conflict with one’s sense of moral
integrity often evoke high levels of anxiety and doubt because of their
mere presence; for example: “What do the thoughts mean about who I re-
ally am?” or “Will I lose control and act on the impulses?” Obsessions
might be at odds with the patient’s sense of self in other ways as well; for
example, contamination obsessions that occur among individuals who
pride themselves on their cleanliness, obsessions with symmetry or or-
derliness that threaten one’s feelings of perfection, or other senseless re-
petitive thoughts that represent a threat to one’s idea of himself or herself
as rational and in control of his or her thinking.
The third functional characteristic of obsessions is subjective resistance—
the sense that the obsession must be dealt with, neutralized, or altogether
avoided. Whereas compulsive behaviors are the most common (and ob-
servable) tactics used by individuals with OCD, a repertoire of other strate-
gies may be used as well, including thought suppression, distraction,
thought replacement, avoidance, rationalizing, and other mental or physi-
cal maneuvers (Freeston & Ladouceur, 1997). The motivation to resist is ac-
tivated by the fear that if action is not taken, disastrous consequences, such
as physical or mental harm to oneself or others, may occur. Less commonly,
patients worry that if the obsession is not dealt with, anxiety, uncertainty, or
a sense of imperfection will persist indefinitely or spiral to ever-increasing
and unmanageable levels. Patients vary with respect to how easily they can
articulate such concerns.
12 CHAPTER 1
Lee and Kwon (2003) proposed two types of obsessions. Reactive obses-
sions are worry-like doubts evoked by situations or stimuli that carry a de-
gree of uncertainty or risk that the person finds anxiety evoking (e.g., “I
might have bathroom germs on my clothes”). Although reactive obsessions
are usually recognized as excessive, the person might suspect that a feared
consequence is likely. Thus, the occurrence or severity of a dreaded out-
come is strongly resisted. Examples include concerns about contamination,
making mistakes, accidents, and asymmetry. In contrast, autogenous obses-
sions are personally unacceptable intrusive thoughts, images, or urges that
might either come to mind spontaneously or be prompted by external situ-
ations (i.e., the sight of a religious symbol may trigger an unwanted sacrile-
gious thought or image). Intrusive blasphemous or “immoral” thoughts
and inappropriate sexual or aggressive impulses fall into this category. Be-
cause such thoughts are experienced as highly repugnant, they are readily
perceived as irrational and the thoughts themselves are strongly resisted.
In summary, obsessions are doubts, thoughts, impulses, images, fears,
or other types of cognitive phenomena that are personally relevant yet
confined to a somewhat restricted range of topics. To varying degrees,
people with OCD perceive their obsessions as intrusive and uncontrolla-
ble, inconsistent with their personal belief system or sense of self, and anx-
iety or distress producing. Given how obsessions are experienced it is not
surprising that people with OCD engage in efforts to resist them with the
aim of escaping from emotional discomfort. Traditionally, stereotyped
compulsive rituals have been considered the primary means of resistance.
Next, I encourage the clinician to think in line with current research indi-
cating that compulsions represent only one of numerous overt and covert
safety-seeking strategies that patients may deploy in their attempts to
neutralize obsessional fear.
SAFETY-SEEKING BEHAVIOR: COMPULSIONS

AND NEUTRALIZATION STRATEGIES
Salkovskis (1991) defined safety-seeking behavior as behavior that is per-

formed to minimize or prevent a feared consequence. He further suggested
that such behaviors explain why the nonoccurrence of a feared conse-
quence fails to reduce the patient’s fear. For example, a patient with con-
tamination obsessions continues to fear becoming very sick from touching
his shoes because every time he touches them, he ritualistically washes
himself. When he does not become ill, he believes, erroneously, that his
washing ritual is the reason this is so. The ritual prevents him from learning
that shoes do not typically make people sick. The following text describes
the various forms of safety behavior observed in OCD.
Overt Compulsive Rituals
Compulsive rituals are the most conspicuous features of OCD and, in many
instances, account for most of the sufferer’s functional impairment.
Rachman (2002) proposed that the necessary and sufficient conditions for
describing a repetitive behavior as compulsive are (a) performance of the
behavior in response to an urge or pressure to act, and (b) attribution of the
urge to internal sources. Some OCD patients make strong efforts to resist or
delay their compulsive rituals (with occasional success), whereas others
make little or no effort. Resistance may be strongest in the early stages of the
disorder, with patients relaxing their fight against compulsive urges the
longer they struggle with OCD (Tallis, 1995). When not bothered by obses-
sional fears, patients can often recognize that their compulsive urges are
senseless and excessive. Although a relationship between obsessions and
compulsions is the norm, some compulsive behaviors may not be directly
connected to obsessions, yet they are still clearly senseless and excessive.
Form and Function. The DSM specifies that compulsions in OCD are
motivated and intentional, in contrast to mechanical, robotic, repetitive be-
haviors (e.g., tics) as observed in disorders such as Tourette’s syndrome.
Moreover, compulsions are performed to reduce distress, in contrast to re-
petitive behaviors in addictive or impulse-control disorders (e.g., sexual
addiction, trichotillomania), which are carried out because they produce
pleasure or gratification.
Table 1.4 displays the various thematic categories of compulsions as
assessed on the Y–BOCS–SC, as well as the percentage of individuals
seen in our clinic with each category. The far right column of Table 4.1
presents examples of compulsive rituals from patients in our sample. In
many instances it is clear that compulsive rituals are performed to re-
duce obsessional anxiety about particular feared consequences. Exam-
ples include compulsively checking appliances to reduce fears of
electrical fires, or cleaning rituals intended to remove contaminants and
thereby avoid sickness. In other cases, patients have difficulty articulat-
ing the presence of particular feared consequences, and instead perform
rituals to reduce anxiety (or other forms of distress) or to achieve an
ill-defined feeling of completeness.
Although rituals are intended to reduce distress, patients sometimes re-
port that performing compulsive behavior evokes additional distress
(Rachman & Hodgson, 1980). This may occur as a result of frustration with
not being able to control seemingly senseless compulsive urges, or if there
is obsessional doubt over whether the ritual was performed to completion.
For example, one woman we evaluated found her showering ritual ex-
tremely distressing because she was unable to decide when she was clean
TABLE 1.4
Primary Compulsions Reported by 145 Patients With OCD
Category n (%) Case Example

Checking 86 59.3 Checks locks, windows, lights, appliances
Checks that sleeping child is still breathing
Rechecks work assignments
Checks with doctors or nurses to rule out serious illness
Carefully inspects all empty envelopes before dis-
carding
Cleaning/ 80 55.1 Ritualized shower and toilet routine
Washing
Uses rubber gloves to handle laundry
Cleans shower stall before taking a shower
Rinses hands in excess of 40 times per day
Ordering/ 64 44.1 Arranges books in particular manner
Arranging
Puts on clothes in a particular order
Mental 61 42.1 Repeats the phrase “nothing, no one, nowhere” to
rituals himself
Repeats “I love Jesus Christ with all my heart” three
times to herself
“Cancels out” unacceptable thoughts with “good”
thoughts
Reviews conversations to ensure she didn’t say curse
words
Repeating 49 33.8 Rewrites bank checks
Turns light switch on and off repeatedly until feels
just right
Counting 43 29.7 Counts breaths to avoid odd numbers
Hoarding 32 22.1 Collects empty grocery bags and envelopes
Collects items that could be used as art supplies
Miscellaneous 73 50.3 Confesses all “bad” thoughts to his mother
Asks the same questions to gain reassurance
Confesses the same sins repeatedly to priest
Note. Up to three primary compulsions were identified for each patient.
14
enough. Thus, she remained in the shower until the hot water ran
out—sometimes as long as 2 hours. In some instances rituals become so
burdensome that patients try to avoid situations that would evoke compul-
sive urges. For instance, the woman just described eventually refrained
from leaving her home to avoid feeling contaminated because that would
trigger the irresistible urge to shower.
Less is understood about senseless and excessive compulsive behav-
iors that are performed to reduce discomfort yet are not linked with obses-
sional fears of danger or harm. Rachman (1974) described a subgroup of
OCD patients with obsessional slowness who spend exceptional lengths
of time repeating routine tasks such as reading and writing, dressing, ar-
ranging items, or walking through doorways. The reason for their slow-
ness was the need to perform these activities “perfectly.” Rasmussen and
Eisen (1992a) proposed that such patients have “an inner drive that is con-
nected with a wish to have things perfect, absolutely certain, or com-
pletely under control” (p. 756). More recently, Coles, Frost, Heimberg, and
Rheaume (2003) hypothesized that compulsive rituals that are not per-
formed to reduce specific fears of harm may be carried out in response to
distress associated with obsessional concerns about things (including
mental states) not being “just right” or perfect.
Rachman and his colleagues examined the functional properties of
compulsions in a series of elegant experiments in which patients were ex-
posed to stimuli that provoked compulsive urges and asked to report
their level of anxiety and urge to ritualize. The findings of these studies
can be summarized in the following way: For patients with washing ritu-
als that were evoked by fears of dirt and germs, exposure to contaminants
led to an increase in subjective anxiety and urges to ritualize, whereas
completion of a washing ritual rapidly reduced this distress. A more grad-
ual spontaneous reduction in both anxiety and compulsive urges was also
observed when the performance of rituals was delayed for 30 minutes
(Hodgson & Rachman, 1972). Similar results were obtained in two studies
of patients with checking rituals that were evoked by exposure to poten-
tially harmful stimuli such as knives (Roper & Rachman, 1976; Roper,
Rachman, & Hodgson, 1973).
These studies are of utmost importance because they empirically dem-
onstrate the functional link between obsessional anxiety and compulsive
behavior in OCD. In behavioral terms, this research sheds light on how
compulsive rituals are negatively reinforced by their consequences. That is,
because rituals bring about a more rapid decline in obsessional anxiety
than if the ritual was delayed or not performed, the patient is likely to resort
to compulsive behavior as a habitual response to obsessional anxiety. This
relationship between anxiety-evoking obsessions and anxiety-reducing
compulsions (although not always readily apparent) is what sets OCD
16 CHAPTER 1
apart from most other disorders that involve repetitive thinking and behav-
ior—it is the essence of OCD. For this reason, during assessment it is critical
to ascertain the presence and nature of this relationship.
Although compulsions reduce anxiety in the short term, they are
maladaptive in the long run because of how patients interpret their out-
come. Specifically, when obsessive fears do not materialize patients be-
lieve that it was their rituals that prevented such disasters. This
strengthens the obsessional fear (and the ritualistic urge) by fostering the
notion that rituals are necessary to prevent catastrophe. Patients might
also believe that without performing the ritual, obsessional anxiety
would have continued indefinitely. Put another way, compulsive behav-
ior in OCD blocks patients from finding out that their obsessional fears are
unrealistic. For example, suppose David, who has an obsessional fear that
his mother will die unless he counts to 10, dares to resist performing this
counting ritual and his mother does not die. His obsessional fear will have
been invalidated. If he repeatedly has similar experiences, David will ac-
cumulate disconfirmatory evidence that will weaken his belief that the
counting ritual prevented his mother from dying. However, if David con-
tinues to engage in compulsive counting and his mother does not die, he
will continue to attribute this to the compulsive counting and his fear will
be strengthened. In similar situations, patients often say things such as,
“If I had not washed my clothes, I would have become ill,” “If I don’t
check that the door is locked, there will be a burglary,” or “If I didn’t get
dressed the right way I would never feel right.”
Because compulsive rituals bring about an immediate reduction in ob-
sessional fear (i.e., they are an escape tactic), they are negatively reinforced
and likely to be repeated. This repetition serves to strengthen the self-per-
petuating vicious cycle displayed in Fig. 1.1. Understanding this pattern of
phenomenology leads to the use of certain treatment procedures that can
weaken this cycle. In particular, repeated exposure to obsessional cues
while simultaneously refraining from compulsive behavior will teach pa-
tients two things. He or she will learn, first, that the feared consequences are
unlikely to occur even if no compulsive behaviors are performed, and sec-
ond, that compulsive rituals are unnecessary to reduce obsessional fear.
Mental Rituals
As Table 1.4 indicates, a substantial proportion of individuals with OCD

engages in mental compulsions—repetitive mental acts aimed at prevent-
ing a negative outcome (also called covert or cognitive rituals). Because men-
tal rituals are purely cognitive phenomena and therefore less tangible than
overt rituals such as checking and washing, they may be difficult to distin-
guish from obsessions. However, as with behavioral rituals, mental rituals
FIG. 1.1. The self-perpetuating cycle of obsessions and compulsions in OCD.
are intentional acts that are performed to reduce distress (de Silva, Men-
zies, & Shafran, 2003). Obsessions, in contrast, are involuntary anxi-
ety-evoking thoughts. Examples of common mental rituals include
repetition of special phrases, prayers, or numbers in a specific manner,
and ritualistically going over (mentally reviewing, analyzing) one’s be-
havior or conversations to reassure oneself that one has not made egre-
gious mistakes or said anything offensive. The following example
illustrates a somewhat elaborate mental ritual.
Stefanie was an unmarried department store clerk who lived with her parents.
Her severe OCD symptoms interfered substantially with social, leisure, and
work functioning. Among her symptoms was a complex mental ritual that she
referred to as “being born again.” This ritual was evoked by obsessional doubt
associated with unacceptable thoughts such as “my life will always be out of
control,” or “OCD will run my life forever,” that often came to mind and caused
significant distress. To execute the ritual, Stefanie had to undress and lie, in the
nude, on her parents’ bed in a fetal position with her eyes closed. She then had
to conjure up the following mental images in order: (a) her parents having in-
tercourse, (b) herself being conceived from a sperm and egg, (c) herself as a fe-
tus growing in her mother’s womb, and (d) her birth.
At first, completing this ritual took Stefanie only about 3 minutes. However,
she became increasingly uncertain about whether she was visualizing the im-
ages “perfectly” enough to make the ritual “really count” and began starting
over from the beginning if she even slightly lost her train of thought during
the ritual. When Stefanie came to our clinic she reported spending over 2
hours getting through this ritual each day.
18 CHAPTER 1
Mental rituals are functionally equivalent to overt rituals in that the urge
to perform them is evoked by obsessional fear, and successful performance
of the ritual results in an immediate reduction of fear and of the compulsive
urge (de Silva et al., 2003). As with overt compulsions, urges to perform
mental rituals decline on their own over time if the ritual is not performed.
In fact, de Silva et al. (2003) found that urges to carry out mental rituals sub-
sided within 15 minutes even if the mental ritual was not performed. As
with behavioral rituals, mental compulsions (a) are maintained by negative
reinforcement because they reduce distress, and (b) prevent the
disconfirmation of obsessional fear.
Compulsive Reassurance Seeking
Many individuals with OCD engage in repeated attempts to gain “ulti-

mate” certainty that the feared consequences featured in obsessions will
not (or did not) occur. Requests for assurance may take various overt and
covert forms and are evoked by obsessional doubt and intolerance for un-
certainty. The most straightforward style is overt questioning. For example,
Hayden had been with his parents at the bedside of his grandfather who
was dying of cancer. Even though the event was a peaceful one, Hayden
continued to be tormented with obsessional thoughts that perhaps when
no one was looking, he had killed his grandfather by smothering him with a
pillow. When these intrusions occurred, they evoked doubt and distress,
which the patient dealt with by frequently asked his parents, “Are you sure
I didn’t kill Grandpa?” Some patients try to disguise their reassurance seek-
ing by asking the same question in a slightly different way (e.g., “How did
Grandpa die?”).
Reassurance seeking provides the patient with no new information and
is therefore simply an attempt to reduce anxiety. That is, the person can usu-
ally guess correctly the answers to his or her reassurance-seeking ques-
tions; yet he or she feels very anxious and engages in emotional reasoning
wherein logic is dictated by emotions (“There might be something wrong
because I feel anxious”). Although seeking reassurance may bring about
short-term relief from obsessional doubt, patients rarely get the ultimate
guarantee they are looking for. This is, of course, because complete cer-
tainty is rarely an option, especially for patients who tend to want reassur-
ance about obscure doubts such as “Am I going to heaven when I die?”
“How hard do I need to concentrate when saying my wedding vows to
make them count?” and “How long must I wash my hands to be sure I have
no germs?” A useful way of understanding urges to seek reassurance is to
consider that whereas people without OCD tolerate acceptable levels of
risk and uncertainty all the time (e.g., driving, crossing the street), those
with OCD have trouble taking such risks when it comes to their obsessional
fears. They wish to have a 100% guarantee of safety. The following example
illustrates an elaborate form of reassurance seeking.
Steve, a 25-year-old medical student, described obsessional doubts that some

years earlier he had injured his rectal sphincter muscle while having a bowel
movement. Although a series of medical examinations suggested no abnor-
malities, Steve’s need for assurance that he would not become bowel inconti-
nent persisted. In addition to compulsively checking his rectal muscle tone
using his fingers, Steve regularly sought guarantees from his physician and
his medical school professors that one cannot permanently injure one’s
sphincter in this way. Notwithstanding his doctors’ initially sincere efforts to
provide the most accurate medical and logical reassurance, Steve could not be
convinced. He began tracking down his professors or calling them at home
when desperate for relief from obsessional doubt. The continual pestering of
faculty members for an “absolute guarantee” became irritating to the point
that Steve was asked to take a leave of absence. Despite all of his attempts to
gain certainty, and despite no evidence of unhealthy muscle tone whatsoever,
Steve saw himself as relegated to a life of horrible embarrassment. He was
avoiding intimacy, using adult incontinence products, and having problems
with depression.
A more clandestine method by which patients may seek reassurance is to

closely observe how others respond to certain situations or stimuli. For ex-
ample, one patient with contamination fears surreptitiously cajoled others
to accompany him to public bathrooms. The patient then watched the other
person’s reaction to the bathroom very closely to gauge whether the bath-
room was “safe enough” for him. It is important for the clinician to be cog-
nizant of subtle attempts to obtain reassurance because these behaviors,
like overt compulsions, strengthen obsessional fear.
Neutralization
Most people with OCD use additional overt and covert strategies that do
not meet DSM criteria for compulsions (i.e., they are not stereotyped or re-
peated according to rigid rules) to control, remove, or prevent their obses-
sions (Freeston & Ladouceur, 1997; Ladouceur et al., 2000). On one hand,
these neutralization strategies resemble compulsive rituals in that they are
attempts to reduce anxiety. However, whereas compulsions are intended to
prevent negative outcomes, patients use neutralization to offset obses-
sional thoughts; and this may or may not be an attempt to prevent a feared
outcome (Rachman & Shafran, 1998; Salkovskis, 1985). Individuals may
use different strategies to neutralize different thoughts and different strate-
gies to cope with the same thought (Freeston & Ladouceur, 1997).
Researchers have identified several general categories of neutraliza-
tion responses including overanalyzing and rational self-talk (i.e., to con-
vince oneself of the unimportance of the thought), seeking reassurance,
20 CHAPTER 1
replacing the thought with another thought, performing a brief mental or

behavioral act, distraction, and thought suppression (Ladouceur et al.,
2000). The choice of neutralizing strategy may be influenced by the inten-
sity of the obsessional thought, the context in which it occurs, how the
thought is appraised, and how well particular strategies have “worked”
in the past (Freeston & Ladouceur, 1997). Neutralizing can take infinitely
diverse forms, and some of these strategies may be remarkably subtle.
The key to recognizing and understanding such symptoms is to identify
their antecedents (i.e., obsessional thoughts) and consequences (i.e., es-
cape from the thought; anxiety reduction). To this end, a thorough assess-
ment of the patient’s cognition and behavior, as is described in later
chapters, is imperative.
The following examples illustrate various kinds of neutralization
strategies.
• One man gripped the steering wheel more tightly (brief behavioral
act) when he experienced distressing thoughts of intentionally killing
his family by driving his car into opposing traffic.
• A young woman always removed her jacket and wore tight clothing
when she shopped to neutralize obsessional thoughts that others
might think she was stealing (brief behavioral act).
• A man with unacceptable thoughts of awakening during the night
and urinating on his furniture neutralized the thoughts by picturing
himself using the toilet and by leaving the bathroom light on (brief
mental and behavioral acts).
• A heterosexual woman with unwanted thoughts about what it would
be like to be a lesbian tried to suppress and dismiss such ideas as they
came to mind (thought suppression).
• A woman with obsessional thoughts of harming her unsuspecting
husband confessed these thoughts to him whenever they came to her
mind (social strategy). She explained to her therapist, “If I tell my hus-
band that I’m thinking about hurting him, he’ll be ready to stop me if I
start to act.”
A number of studies confirm that neutralization and overt compulsive

rituals have similar functional properties. Both are deliberate and effortful,
and both serve as a temporary escape from obsessional distress (e.g.,
Rachman, Shafran, Mitchell, Trant, & Teachman, 1996; Salkovskis, West-
brook, Davis, Jeavons, & Gledhill, 1997). Indeed such strategies become ha-
bitual because they provide rapid escape from obsessional distress (i.e.,
negative reinforcement). However, in the long run, neutralizing is a
maladaptive response because, as with compulsive rituals, patients attrib-
ute the nonoccurrence of disastrous consequences to their neutralization

efforts, thereby preserving their obsessional fears.
Avoidance and Concealment
Passive avoidance is present to some degree in most individuals with

OCD and is intended to prevent exposure to situations that would evoke
obsessional thoughts and compulsive urges. For some patients the aim
of avoidance is to prevent specific consequences such as contamination
or illness, whereas in other instances avoidance is focused on preventing
obsessional thoughts from occurring in the first place. For example, one
woman avoided using public staircases because they evoked thoughts
and fears of impulsively pushing unsuspecting people down the steps.
Other patients engage in avoidance so that they do not have to carry out
tedious compulsive rituals. For instance a young man with obsessional
fears of contamination from his family’s home computer (because it had
been used to view pornography) engaged in elaborate and time-con-
suming compulsive cleaning and showering rituals. During the morn-
ing and afternoon he avoided the computer room so that he would not
have to perform these rituals during the day. In the evening, however, he
relaxed his avoidance and allowed himself to enter the room and become
contaminated knowing that he could “work in” his ritualistic showering
before bedtime.
Newth and Rachman (2001) elaborated on a different form of avoidance
in which patients deliberately conceal from others the content and fre-
quency of their intrusive and repugnant obsessions. Usually it is unaccept-
able sexual, blasphemous, and violent images; impulses to harm loved
ones; and senseless thoughts about contamination that are hidden from
others. This concealment may occur for a variety of reasons, the most obvi-
ous of which is the fear that others will respond negatively to hearing about
the thoughts or regard the person as dangerous or sick.
As with the various forms of compulsive behavior and neutralization,
avoidance and concealment are maladaptive in that they provide short-term
protection or relief from obsessional fear, yet have insidious longer term ef-
fects. By avoiding or concealing, the individual never has the opportunity to
find out that obsessional situations are not high risk, and that obsessional
thoughts are not as significant as is feared. Thus, in the end, these two strate-
gies contribute to the persistence of obsessional fear. Concealment of obses-
sions also increases preoccupation with the concealed thought and ensures
that the person will not receive corrective feedback about the normalcy of
such thoughts. Therefore, the sufferer continues to believe that his or her in-
trusive thoughts are rare or dangerous.
22 CHAPTER 1
SUBTYPES AND DIMENSIONS OF OCD
Although there are grounds for conceptualizing OCD as a homogeneous

disorder, the prominence of particular features in particular patients is an
obvious clinical reality. Whereas some patients are overly concerned with
contamination and compulsively wash their hands to modulate distress,
others who are equally impaired spend inordinate amounts of time repeat-
ing mundane activities to achieve “just right” feelings. Still others may be
tormented by intrusive unacceptable thoughts of blasphemy, sex, or vio-
lence, or have to repeatedly check to allay persistent obsessive doubt. Al-
though thematic shifts are common over time, the symptoms occurring at
any given point are internally consistent and have meaning to the patient.
That is, patients with washing rituals feel they must wash to reduce con-
tamination. Those with compulsive praying rituals describe fears of pun-
ishment from God. Individuals who check say that they fear being
responsible for harm. Observations that some symptom themes are less re-
sponsive to treatment than others suggest that it is useful to distinguish be-
tween different presentations of OCD (for a review see McKay et al., 2004).
A number of researchers have used multivariate statistical methods to
derive symptom subtypes or dimensions using the Y–BOCS–SC. The find-
ings from these studies, which have examined hundreds of patients with
OCD, indicate that the following thematic presentations of OCD exist: con-
tamination obsessions with washing rituals; aggressive/sexual/religious
obsessions with checking rituals; symmetry obsessions with ordering/re-
peating/counting compulsions; and hoarding obsessions and compul-
sions (e.g., Leckman et al., 1997). One problem with these studies is that the
Y–BOCS–SC does not adequately assess the full range of safety behaviors.
For example, mental compulsions and neutralization are left out. Because
about 80% of OCD patients report mental rituals, and about 10% report
mental rituals as their most common compulsions (Foa & Kozak, 1995), the
thematic schemes that are reported in these studies are incomplete.
In a more definitive study of the various presentations of OCD, my col-
leagues and I at Mayo Clinic and the University of Pennsylvania used an
updated version of the Y–BOCS–SC that incorporated a separate mental rit-
uals category (Abramowitz, Franklin, Schwartz, & Furr, 2003). This allowed
us to more carefully study how mental rituals such as repeating “safe”
phrases, numbers, images, prayers, mental counting, list making, and men-
tally reviewing (e.g., conversations) were related to other types of OCD
symptoms. Using a large sample of patients (N = 132) we found five stable
presentations of OCD with predominant patterns of obsessions and com-
pulsions, including (a) harming, (b) contamination, (c) symmetry, (d) unac-
ceptable thoughts with covert rituals, and (e) hoarding. Table 1.5 shows the
percentage of patients in our sample with each presentation. Although we
TABLE 1.5
Frequency and Percent of Patients With Different OCD Symptom Subtypes
Subtype Number of Patients %

Harming 29 22.0
Contamination 33 25.0
Symmetry 13 9.9
Hoarding 16 12.0
Unacceptable thoughts 41 31.1
Note. Total sample size was 132. From “Symptom Presentation and Outcome of Cognitive-
Behavior Therapy for Obsessive–Compulsive Disorder,” by J. S. Abramowitz, M. E. Franklin, S.
A. Schwartz, & J. M. Furr (2003), Journal of Consulting and Clinical Psychology, 71, 1049–1057.
Copyright 2003 by American Psychological Association. Reprinted with permission.
clustered patients into groups according to their symptom presentation, it

is probably more useful to think about the heterogeneity of OCD in terms of
symptom dimensions because a given patient may experience different pre-
sentations to varying degrees (i.e., high, medium, or low on each dimen-
sion; Taylor, 2005). Moreover, the majority of patients evidence multiple
symptom themes. Next, the essential phenomenology of each symptom
dimension is discussed.
Harming
The chief obsessional symptoms in the harming dimension include unreal-

istic fears of responsibility for inflicting physical or emotional injury to one-
self or to others. Patients may be overly concerned about possible accidents,
mistakes, fires, burglaries, or hurting others’ feelings. They have obsessive
doubts such as “Am I absolutely certain I unplugged the iron?” or “What if
I hit someone with my car and didn’t realize it?” Some patients display ob-
sessional fear of “unlucky” words, numbers, colors, or serious illnesses that
they magically associate with disastrous consequences (e.g., saying the
word cancer makes cancer more likely).
In an attempt to gain certainty that harm is unlikely, individuals with
this presentation of OCD typically engage in compulsive checking.
Checking occurs when individuals who believe they have a responsibility
for preventing harm feel uncertain about whether a perceived risk has
been adequately reduced or removed (Rachman, 2002). Such rituals may
be elaborate and involve repeated checking of all doors, windows, lights,
and electrical outlets before going to bed or leaving the house. Inordinate
amounts of time may be spent checking for mistakes, such as when paying
24 CHAPTER 1
bills, addressing envelopes, or completing forms and school assignments.

Checking might also involve compulsive reassurance seeking, mentally
reviewing past behavior to check for feared mistakes, or counting to en-
sure avoidance of unlucky or harmful numbers (e.g., 13, 666). As
Rachman (1976) noted, checking occurs predominantly in the person’s
home environment and when the person is alone. It may be more intense
when the person is under additional distress or is experiencing depres-
sion, yet is most severe when the person feels highly responsible. Some
patients perform repeating rituals, such as rereading or rewriting, or the
repetition of routine behaviors (e.g., going through a doorway, looking
twice at something) because they believe such rituals prevent harm or bad
luck. There might be a certain safe number of times that such checking or
repeating rituals must be repeated (e.g., multiples of 7).
Case D
escription.
Marcia and her husband managed a dog kennel. Marcia’s most prominent ob-
sessions included thoughts that the dogs might get injured or become ill (i.e.,
with ringworm) and that the dog owners would hold her and her husband li-
able. Such fears motivated Marcia to engage in a range of checking rituals in-
cluding excessively examining each of the 20 to 30 dogs in the kennel multiple
times each day and enlisting others to check on the status of the dogs if she
was away from the kennel for more than an hour at a time. At intake, Marcia
was spending more than 3 hours each day checking the kennel dogs’ health.
She acknowledged that her behavior was extreme compared to what other
kennel managers do. However, she also described feeling compelled to know
“for sure” that the dogs had not been injured. Marcia also checked locks, ap-
pliances, and water faucets before leaving the house and every night before
going to bed. She noted that her checking rituals always took longer if her
husband was away from home.
Contamination
Obsessions in the contamination dimension commonly include excessive
and unreasonable fears of diseases from bodily fluids (e.g., blood, sweat,
urine, feces, saliva, semen), harm from dirt, or germs, and pollution from
environmental toxins such as asbestos or household items such as bleaches
or solvents. Some individuals fear becoming sick from contaminants and a
subset worry that they will contaminate others. In some instances it is as if
the idea or feeling of being contaminated is the focus of concern over and
above any specific illnesses. The transmission of contamination is typically
by contact and Tolin, Worhunsky, & Maltby (2004) found that contamina-
tion could be “spread” from object to object without a reduction of the in-
tensity of the contamination. More than other OCD presentations,
contamination fears seem similar to the symptoms of specific phobia in
which individuals go to great lengths to avoid confronting discrete anxi-
ety-evoking stimuli (e.g., restrooms, floors, shoes). This may be contrasted

with the harming subtype in which fear is evoked primarily by doubts re-
garding possible negative consequences. Most patients with contamina-
tion symptoms display hypervigilance for sources of contamination and
may retain a precise memory of the nature and exact location of such stim-
uli going back many years (Rachman, 2004).
Contact with the contaminants just described (sometimes even imag-
ined contact) evokes a sense of dirtiness and instigates attempts to remove
the pollutant. The primary compulsive “decontamination” behaviors are
excessive cleaning and washing (of oneself or inanimate objects), including
ritualized showering, bathing, bathroom routines, and excessive use of
handy wipes or disinfectant hand gels. Whereas some patients with wash-
ing and cleaning compulsions perform higher frequencies of brief rituals
(e.g., 50 brief hand rinses per day), others engage in fewer, yet more
time-consuming rituals (e.g., daily 90-minute showers). The function of
these behaviors is to prevent the spread of contaminations or to reduce the
chances of harm. However, over time such behaviors can become stereo-
typed and robotic (Rachman, 2004). The feeling of contamination also
evokes avoidance behavior and attempts to prevent contamination. Some
patients establish sanctuaries (e.g., one’s own room) that they take espe-
cially great care to keep uncontaminated. The use of barriers (e.g., paper
towels, gloves) when touching surfaces or opening doors is common, yet
patients may also take more exorbitant measures to prevent or remove
contact with feared contaminants, including changing clothes or bed linens
more often than necessary.
In some ways, decontamination rituals resemble checking rituals in that
both are intended to reduce obsessional distress, uncertainty, and the
chances of harm. For patients with cleaning rituals, the source of uncer-
tainty is that the feared contaminants are typically microscopic. Thus, the
extent of possible contamination and how much cleaning must be done to
decontaminate are both unknowns. Whereas situations in which definite
contact with contaminants has occurred will likely evoke rituals, so may
situations where there might have been contact. Rituals and avoidance are of-
ten performed in accordance with “rules” acquired (and often exaggerated)
from outside sources (e.g., to avoid sickness one should wash for 30 sec-
onds after using the bathroom; the herpes virus can live for 18 hours on a
toilet seat). A difference between checking and cleaning rituals is that
whereas checking is intended to prevent future harm, the goal of cleaning
rituals is often to remove potential danger (e.g., contamination from germs).
In addition, whereas checking rituals often serve to protect others from
danger, cleaning usually serves to protect oneself. In our study, patients
with this presentation of OCD were unique in that they evidenced very few
non-contamination-related obsessions and compulsions.
26 CHAPTER 1
Case Description.
Matt, a 35-year-old unmarried man, worked as a repairman for a cable TV

company. His current obsessional fears concerned becoming sick via contam-
ination from feces. He worried about stepping in dog feces while at work and
therefore avoided grassy areas or homes where he thought there might be
dogs. Compulsive behavior included frequent hand washing and changing
his shoes or clothes. Even if he saw dog feces without stepping in it, Matt wor-
ried whether he had come close enough to get any germs. Such situations
evoked irresistible urges to change his shoes and wash his hands. Other
sources of contamination included the mail and certain public places he asso-
ciated with dog feces. Matt’s apartment was his “safe haven.” Except for his
bathroom, he considered everything in his living space to be clean. Before go-
ing into his apartment, Matt would perform a decontamination ritual that in-
cluded removing his shoes and some of his clothing before entering, and not
touching anything until he reached the bathroom. Once in the bathroom Matt
showered and then avoided touching the toilet or shower curtain because
these were considered contaminated. Anything he brought into his apart-
ment, such as groceries, had to be cleaned in the bathroom before it could be
placed in other rooms. All mail was opened in the bathroom as well. When
Matt was evaluated at our clinic he was spending a total of more than 8 hours
each day performing compulsive cleaning rituals.
Incompleteness
Research indicates that most individuals with and without OCD at some
time experience the feeling that something is not “just right”; that is,
they have “not just right experiences” (NJREs; Coles, Frost, Heimberg, &
Rheaume, 2003; Leckman, Walker, Goodman, Pauls, & Cohen, 1994). In
OCD, incompleteness primarily involves obsessions with order, neat-
ness, symmetry, and feelings of discomfort evoked by the NJREs. Com-
pulsive behavior largely involves ordering and arranging or repeating
behaviors until the “just right” feeling is achieved. Calamari et al. (1999)
asserted that patients with this symptom profile have a high need for
certainty that things are just so. Coles, Frost, Heimberg, and Rheaume
(2003) suggested these symptoms represent a specific form of perfec-
tionism that is unique to OCD.
The clinician must be careful to distinguish between symmetry or ex-
actness symptoms that are associated with NJREs and those associated
with magical thinking. The latter is characterized by a belief that if objects
are not in the “correct” position, disastrous consequences will result (e.g.,
bad luck, someone will die). Other patients with incompleteness symp-
toms perform ordering rituals to achieve a perfect state of cleanliness. Pa-
tients with this symptom subtype might also repeatedly check to ensure
that something has been done perfectly for the sake of perfection, rather
than to prevent disastrous consequences. Coles, Frost, Heimberg, and
Rheaume (2003) proposed that for patients with incompleteness symp-
toms, the feeling of imperfection or incompleteness may be a feared con-

sequence in its own right.
Case Description.
Karen’s chief OCD symptoms involved ordering and arranging items until
she was satisfied that they looked “perfect.” This included making sure that
photos in all of her albums were arranged just right, that pictures were hung
evenly on the wall, that her closet was perfectly arranged (clothes folded per-
fectly), and that her writing was perfect. Even casual writing tasks were im-
paired. For example, she was unable to write love notes to her boyfriend, send
cards during the holidays, or balance her checkbook without having to erase
or rewrite many times before being satisfied with how her handwriting
looked. Karen reported that her compulsive urges were motivated by a sense
of imperfection that was somewhat difficult to describe, but which was asso-
ciated with fairly intense affective distress. She felt that if she did not achieve
a sense of completeness, her level of discomfort would persist indefinitely
and increase to intolerable levels. She strongly wished not to rewrite or ar-
range items, yet was unable to resist her urges to do so.
It is important to distinguish between incompleteness symptoms in

OCD from those observed in obsessive–compulsive personality disorder
(OCPD). Patients with OCD describe their need for perfection and ordering
or arranging rituals as unwanted and distressing (i.e., ego dystonic). They
emphasize how such problems interfere with functioning and they wish
not to be bothered by them. In contrast, people with OCPD view their per-
fectionism as worthwhile. They strive to attain perfection because they
have imposed unrealistically high standards for themselves. Thus, they do
not view their symptoms as problematic and often do not welcome the urg-
ing of others that they become more flexible. Whereas the treatment proce-
dures described in this book are likely to be of help to people with OCD
symptoms, they are not designed to reduce symptoms of OCPD.
Unacceptable Thoughts and Covert Rituals
This symptom dimension is characterized by autogenous obsessions that

primarily (but not exclusively) concern violence, sex, or religion. Exam-
ples include intrusive ideas of loved ones injured in accidents; unwanted
impulses to attack or harass innocent people or open the emergency exit of
an airplane during flight; unspeakable thoughts of murdering one’s own
infant; “forbidden” or “perverse” sexual impulses; unwelcome images of
unattractive people nude or having sex; and unacceptable blasphemous
thoughts (e.g., God is dead), images (e.g., of Jesus’ penis), or impulses
(e.g., to defile the synagogue). These are experienced as senseless, repug-
nant, and difficult to dismiss. Moreover, the obsessional content is highly
28 CHAPTER 1
uncharacteristic of the person’s moral, ethical, and behavioral tendencies

and therefore causes high levels of distress and efforts to resist. In particu-
lar, patients worry about the presence, significance, and consequences of
these thoughts (e.g., I might act on the thought; I’m an evil person for
thinking this; I must be crazy because of my senseless thoughts) and con-
clude that they must take preventative measures or banish the thought
from consciousness.
In an effort to reduce the discomfort or perceived risk of danger associ-
ated with having unacceptable intrusive thoughts, patients with this OCD
presentation often resort to covert (mental) rituals such as trying to replace
a “bad” thought with a “good” one. Other safety behaviors include reassur-
ance seeking (to diffuse responsibility), avoidance, thought suppression,
and concealment. For example, one happily married woman complained of
unwanted sexual thoughts about her priest that occurred whenever she en-
tered her church. She believed that it was terribly immoral to have adulter-
ous thoughts in a place of worship, and that God would ultimately punish
her for having such thoughts about a priest. She tried to stop the thoughts
by thinking about more spiritual things (e.g., picturing a large cross),
avoiding the priest, and repeating a special prayer to ask for forgiveness.
Moreover, she refrained from telling anyone else of her “dirty little secret.”
Some patients describe the sense that “naughty” or otherwise unaccept-
able or senseless thoughts can contaminate or ruin stimuli in the environ-
ment. To illustrate, one patient seen in our clinic reported that if certain
senseless thoughts (e.g., germs coming out of the television) or evil images
(e.g., the Devil) came to mind while he was engaged in an action (e.g., turn-
ing the page of a book, walking into a room, eating), he had to repeat the ac-
tion 12 times to neutralize the thought. Otherwise, he feared, everything
else he did would be “tainted” by the unwanted thought.
Based on the scarcity of prototypical observable rituals such as washing
or checking, patients with this symptom presentation have traditionally
been labeled as pure obsessional (e.g., Baer, 1994). This implies that only ob-
sessions are present. However, as I described earlier, careful assessment re-
veals that as with other presentations of OCD, two processes are present
here as well: (a) involuntary anxiety-evoking thoughts (obsessions) and (b)
deliberate anxiety-reducing strategies (mental rituals, neutralizing). Even
experienced clinicians sometimes find it a challenge to distinguish between
these two forms of mental phenomena. Nevertheless, this distinction is
highly important for successful treatment using cognitive-behavioral
methods, as we will see in later chapters. The following example illustrates
how obsessions and mental rituals can appear to be very similar when only
their form and content are considered. A careful functional analysis of the
antecedents and consequences of each phenomenon is required to gain a
complete understanding of the symptomatology.
Case Description.
Dale, a 19-year-old man with no history of violent behavior, described per-

sistent unacceptable intrusive images of physically attacking his mother
and father. The images sometimes occurred spontaneously, but were often
evoked by the sight of potential weapons such as knives, and by certain
words such as kill, murder, and thrash. For some time, Dale’s treatment pro-
viders had labeled him as a pure obsessional because there appeared to be
no anxiety-reducing compulsive rituals—just constant violent images.
However, on conducting a functional analysis, it was discovered that Dale’s
intrusive images of attacking his mother were involuntary and unwanted,
but that he was deliberately and carefully conjuring up the images of attack-
ing his father to neutralize the images of attacking his mother. On careful in-
quiry, Dale explained that he felt the need to replace his mother with his
father in his intrusive images to reduce the intense distress he felt when
thinking of harming a woman. Imagining attacking his father—another
man—on the other hand, was more acceptable to Dale. Thus, the images of
attacking mother were conceptualized as obsessions, and those of attacking
father were considered mental rituals.
Hoarding
Patients with hoarding symptoms collect or save items that realistically

have little or no practical value. The patients are subsequently unable (or
unwilling) to discard such items. Examples of commonly hoarded items in-
clude obsolete newspapers and magazines, old clothes, bags and contain-
ers, pictures, letters, old schoolwork, junk mail, and the like. The resulting
clutter may render entire rooms unusable and jeopardize personal safety or
hygiene (Thomas, 1997). Obsessional concerns among patients with hoard-
ing symptoms include thoughts about the potential use of saved objects, ex-
cessive emotional attachment to them (i.e., hypersentimentality), and the
sense that objects have intrinsic value despite having no practical value
(e.g., It’s too nice to throw away). Whereas some individuals actively ac-
quire items, hoarding is perhaps best conceptualized as avoidance behav-
ior tied to indecisiveness, uncertainty, and perfectionism (Frost & Gross,
1993). That is, hoarding serves to avoid or postpone (a) the anxiety-evoking
decision of whether to discard certain items, and (b) the feared negative
consequences of discarding “important” items (Frost & Hartl, 1996).
Case Description.
Jill, a 52-year-old divorced art teacher, had severe hoarding symptoms that
began when she was in her 20s. Although she saved a variety of things such as
old mail, children’s books, pictures of animals, and plastic containers, Jill’s
main hoarding behavior revolved around her art classes. Her home was
strewn with unclaimed projects from students from as far back as the 1980s,
including drawings, paintings, collages, and even larger sculptures and scen-
30 CHAPTER 1
ery from school plays that she felt she might use again at some point as exam-
ples of good artwork. Jill also had an entire room of lesson plans that she had
downloaded off the Internet or copied from textbooks. Although she planned
to one day use these lesson plans with her classes, this had never actually hap-
pened. She was also accumulating a collection of art supplies to use “just in
case” there were funding cuts to the school’s art program. Thus, countless
rolls of masking tape, bottles of glue, magic markers, popsicle sticks, beads,
and reams of paper were scattered throughout the house in no particular or-
der. Jill refused to discard these items, asserting that some day she might need
them, or could sell them. Meanwhile she was unable to keep relationships
and was embarrassed to have anyone visit her home.
Is Hoarding a Symptom of OCD? Collecting and the inability to dis-

card unneeded items are actually observed across many organic and psy-
chological disorders including dementia, developmental disability,
eating disorders, and psychosis (e.g., Frost, Krause, & Steketee, 1996). Ad-
ams (1973) and Greenberg (1987) first hypothesized an association be-
tween hoarding and OCD. Coles, Frost, Heimberg, and Steketee (2003)
argued that hoarding is a specific symptom of OCD on the basis of (a) cor-
relations between OCD and hoarding symptoms, (b) the presence of
hoarding factors in structural analyses of OCD symptoms, and (c) the pre-
ponderance of hoarding among individuals with OCD. Although such
findings suggest a strong relationship between hoarding and OCD, they
must be interpreted with caution due to selection biases that favored the
inclusion of OCD patients with hoarding symptoms. Clinical observa-
tions suggest functional similarities between some presentations of
hoarding and OCD. For example, among individuals whose hoarding
symptoms are accompanied by other OCD symptom dimensions, hoard-
ing appears to be motivated by obsessional doubt regarding the possibil-
ity that something important could be discarded by mistake. The task of
painstakingly checking all potential garbage for important items becomes
so daunting that the person gives up and retains all sorts of unnecessary
materials. Conceptualized in this way, hoarding appears to fit with the
harming symptom dimension described earlier.
There is mounting empirical evidence that hoarding itself is heteroge-
neous, and not necessarily a specific symptom of OCD. For example,
Grisham, Brown, Liverant, and Campbell-Sills (in press) found factor ana-
lytic evidence that hoarding, although frequently associated with OCD,
constitutes a distinct symptom. Cognitive aspects of hoarding appear
somewhat distinct from cognitions in other OCD symptoms (Steketee,
Frost, & Kyrios, 2003). Moreover, in contrast to patients with OCD and
those reporting mixed OCD and hoarding, those with pure hoarding symp-
toms reported lower levels of negative affect, anxiety, depression, and
worry. Two studies of nonclinical samples by Wu and Watson (2005) indi-
cated that whereas prototypical OCD symptoms such as washing and
checking are strongly correlated with one another, hoarding is only moder-
ately associated with other OCD symptoms. Moreover, individuals with
OCD can be distinguished from patients with other disorders and from
nonpatients on the basis of prototypical OCD symptoms, but not on the ba-
sis of hoarding. Finally, whereas OCD symptoms show consistent
relationships with negative affect, hoarding does not.
Although additional research is needed to clarify the relationship be-
tween OCD and hoarding symptoms, the data just reviewed cast doubt on
the notion of a distinct hoarding symptom dimension. Most likely, when
hoarding occurs along with other OCD symptoms, the hoarding is second-
ary to harming-related doubts regarding the possibility of terrible mistakes
as previously described. Evidence also suggests that hoarding that occurs
in isolation of other OCD symptoms is functionally distinct from OCD.
Given these findings, and considering that cognitive-behavioral treatment
that is usually effective for OCD is less helpful for hoarding (e.g.,
Abramowitz, Franklin, Schwartz, & Furr, 2003), the discussion of OCD
psychopathology and treatment in this book assumes that hoarding symp-
toms as observed in OCD exist as part of the harming symptom dimension.
Clearly, however, additional research on this topic is needed.
A Comment on Symptom Dimensions
It is important to note that the symptom dimensions illustrated here are de-
scriptive, rather than functional. That is, they are based primarily on what
the patient does, as opposed to why or what motivates such behavior. An
example of how this approach can be misleading is the fact that some in-
completeness symptoms involve the fear of disastrous outcomes whereas
others involve concern with perfectionism and not-just-right feelings.
Thus, although these dimensions can be useful for understanding a pa-
tient’s OCD symptoms on a superficial level, they do not substitute for a
thorough functional assessment of cognitive and behavioral phenomenol-
ogy as is described in later chapters.
POOR INSIGHT AND OVERVALUED IDEATION
The DSM–IV criteria for OCD include the specifier “with poor insight”
to denote individuals who view their obsessional fears and compulsive
behavior as reasonable. These patients are also said to have fixed beliefs or
overvalued ideas (OVI), defined as “almost unshakable beliefs that can be
acknowledged as potentially unfounded only after considerable discus-
sion” (Kozak & Foa, 1994, p. 344). To illustrate poor insight, consider the
case of Charles, who had been on a scuba diving trip to the Caribbean
with his 15-year-old son. In the year since this trip, Charles had been tor-
32 CHAPTER 1
mented with the obsessional thought that his son’s scuba gear had been
used by someone with AIDS and was not sufficiently cleaned. He was
sure that it was only a matter of time until his son became an AIDS vic-
tim. Charles’s conviction in this belief was remarkably unshakable de-
spite six negative HIV tests. He had even begun planning for his son’s
bout with AIDS by writing a eulogy to deliver at the funeral. Even fol-
lowing numerous attempts to help Charles logically challenge his fears,
he remained steadfast in his belief.
Although the majority of OCD patients recognize at some point that
their obsessions and compulsions are senseless and excessive, evidence
suggests OCD is characterized by a continuum of insight into the irrational-
ity of these symptoms. In the DSM–IV field study described earlier, Foa and
Kozak (1995) found that of 250 patients with obsessional fears of harmful
consequences, 13% were completely certain their feared consequence
would not occur, 27% were mostly certain, and 30% were uncertain of
whether such consequences would occur. Another 26% were mostly certain
that the feared consequences would materialize, and 4% were convinced
that feared consequences would happen. When clinicians were asked to
categorize patients on the basis of their insight, 5% of the patients were
judged to have never recognized that their symptoms are senseless (i.e.,
have poor insight).
In a further analysis of this data, my colleagues and I (Tolin,
Abramowitz, Kozak, & Foa, 2001) found that levels of fixity of belief vary
depending on the obsessional theme. In particular, poorer insight seems to
be associated most strongly with religious obsessions, fears of making mis-
takes, and unwanted obsessional impulses to act aggressively. A number of
additional studies suggest patients with somatic obsessions (e.g., fears of
serious illnesses, obsessions with physical appearance) have poorer insight
and greater overvalued ideation compared to those with other kinds of
OCD symptoms (Abramowitz, Brigidi, & Foa, 1999; McKay, Neziroglu, &
Yaryura-Tobias, 1997; Neziroglu, McKay, & Yaryura-Tobias, 2000). It is im-
portant to know about insight in OCD patients because there is evidence
that poor insight is related to attenuated treatment outcome with behav-
ioral therapy (e.g., Foa, Abramowitz, Franklin, & Kozak, 1999).
PREVALENCE AND COURSE
Prevalence
OCD was once considered extremely rare in the general population. How-
ever, results from large-scale epidemiological surveys now suggest it is
among the more common adult psychological disorders. The Epidemiologi-
cal Catchment Area survey conducted in five U.S. communities in the 1980s
estimated the lifetime prevalence in adults to be 2.6% (range across the five
sites was 1.9%–3.3%) and the 1-month prevalence at 1.3% (range was
0.7%–2.1%; Karno, Golding, Sorenson, & Burnam, 1988). In Canada (Edmon-
ton), Kolada, Bland, and Newman (1994) reported a 2.9% prevalence rate. A
cross-national study estimated the lifetime prevalence of OCD at 2% world-
wide (range = 0.7%–2.5%; Weissman et al., 1994).
Clinic-based and community studies from around the world report a
slight preponderance of females with OCD (e.g., Weissman et al., 1994; Ras-
mussen & Eisen, 1992b) and there appears to be a rarity of minority groups
among these research samples (e.g., Karno et al., 1988). Weissman et al.
(1994) found substantially lower lifetime rates of OCD in Taiwan compared
to other countries surveyed (0.7% vs. 2.0%). Reasons for racial and ethnic
differences are unclear and may reflect variability in symptom reporting or
differential utilization of mental health care.
Onset
OCD typically begins by the age of 25, and often in childhood or adoles-
cence. Only rarely does it onset after age 50 (Rachman & Hodgson, 1980;
Rasmussen & Tsuang, 1986). Large studies indicate that the mean age of on-
set is earlier in men (about age 21) than in women (age 22–24; Rasmussen &
Eisen, 1992b). Rasmussen and Eisen (1992b) found that among a sample of
512 patients, primary OCD symptoms began before the age of 15 in about
one third, before age 25 in about two thirds, and after age 35 in less than one
fifth of patients.
Although most individuals with OCD do not identify clear-cut
precipitants to symptom onset, researchers have found evidence that
stressful or traumatic events and experiences may play a role for some pa-
tients (de Silva & Marks, 1999; Kolada et al., 1994). Accumulating data also
suggest that OCD symptoms occur at higher than expected rates among
childbearing women and their partners (Abramowitz, Moore, Carmin,
Wiegartz, & Purdon, 2001; Abramowitz, Schwartz, Moore, & Luenzmann,
2003). Moreover, the content of obsessional thoughts among new parents
typically concerns unwanted thoughts and fears of harming their children
(Wisner, Peindl, Gigliotti, & Hanusa, 1999). It seems likely that in this case
the abrupt increase in stress and responsibility that comes with caring for a
newborn infant gives rise to exaggerated obsessional thinking
(Abramowitz, Schwartz, & Moore, 2003).
Course
OCD is a chronic condition with a very low rate of spontaneous remission.

Left untreated, symptoms fluctuate, with worsening during periods of in-
34 CHAPTER 1
creased life stress. In an early study by Rasmussen and Eisen (1988) that
was conducted prior to the widespread availability of effective treatments,
85% of 560 patients had a continuous course with waxing and waning of
symptoms, 10% had a deteriorating course, and only 2% had an episodic
course marked by 6-month periods of full remission. More recently, Skoog
and Skoog (1999) completed a 40-year follow-up study of 144 individuals
with OCD, many of whom had received treatment. These authors found
that 83% of this cohort had improved and 48% no longer met diagnostic cri-
teria for OCD, although about half of the nonclinical individuals reported
some residual symptoms. Steketee, Eisen, Dyck, Warshaw, and Rasmussen
(1999) found a 15% probability of full symptom remission at 1 year and a
22% probability after 5 years. Collectively, these findings suggest that al-
though OCD symptoms are likely to improve with treatment, full recovery
is the exception, not the rule.
Quality of Life
Individuals with OCD show impaired social and role functioning, troubled
romantic and family relationships, diminished academic performance, in-
creased unemployment, and increased receipt of disability income (Koran,
2000). Although the severity of obsessions and coexisting depressive symp-
toms were the best predictors of poor quality of life in one study (Masellis,
Rector, & Richter, 2003), the direction of causality (particularly for depres-
sion) remains unclear. Koran, Thienemann, and Davenport (1996) found
that despite a reduced quality of life, people with OCD did not differ sub-
stantially from the general U.S. population in rates of alcohol abuse, sui-
cide, or marriage. The relatives of OCD patients suffer as well, because
symptoms may result in restricted access to certain rooms, involvement of
others in compulsive rituals, and difficulty in taking vacations (Black,
Gaffney, Schlosser, & Gabel, 1998; Calvocoressi et al., 1995; Magliana,
Tosini, Guarneri, Marasco, & Catapano, 1996). Data from our own sample
of 50 patients indicate that a diagnosis of OCD is related to increased
(nonmental health) medical utilization, and that more severe OCD and de-
pressive symptoms are associated with greater impairment in work or
school, social, and family functioning.
Dupont, Rice, Shiraki, and Rowland (1995) estimated that the direct
cost of OCD on the U.S. economy in 1990 was $2.1 billion, and the indirect
cost (e.g., in lost productivity) was $6.2 billion. Moreover, OCD accounted
for about 6% of the estimated cost of all psychiatric disorders in 1990. Still,
only about 1 in 15 individuals with OCD receive treatment for their condi-
tion (Nestadt, Samuels, Romanoski, Folstein, & McHugh, 1994); and the
delay between symptom onset and obtaining a correct diagnosis and
treatment may be as long as 10 years (Marks, 1992; Rasmussen & Eisen,
1988). Reasons for the lag between onset and treatment initiation include
patients’ concealment of their seemingly bizarre thoughts and behaviors,
and the underrecognition by professionals. Many sufferers only recog-
nize their symptoms as part of OCD after being exposed to media cover-
age about the disorder.
Comorbidity
Individuals with OCD are at an increased risk for additional Axis I and Axis
II psychopathology. Depressive disorders are among the most commonly
co-occurring difficulties (e.g., Crino & Andrews, 1996a; Nestadt et al., 2001;
Steketee et al., 1999). Weissman et al. (1994) found that the lifetime preva-
lence of major depressive disorder (MDD) among OCD patients ranged
from 12.4% to 60.3% across seven countries (M = 29%). In the eastern United
States, Nestadt et al. (2001) reported a lifetime comorbidity rate of 54.1%
and Steketee et al. (1999) reported a concurrent comorbidity rate of 36%. In
Canada (Toronto), Antony, Downie, and Swinson (1998) found that 24.1%
of a large OCD sample presently met criteria for MDD. For the most part,
OCD predates MDD (Demal, Lenz, Mayrhofer, Zapotoczky, & Zitterl,
1993). This suggests that depressive symptoms usually occur in response to
the distress and functional impairment associated with OCD. Depressive
symptoms seem to be more strongly related to the severity of obsessions
than to compulsions (Ricciardi & McNally, 1995).
A number of studies indicate that OCD is often compounded by additional
anxiety problems (Weissman et al., 1994). Table 1.6 shows comorbidity rates
for particular anxiety disorders from three research samples. Nestadt et al.
(2001) found significantly higher lifetime rates of social phobia, panic and gen-
eral anxiety disorder (GAD), but not specific phobia or agoraphobia, among
individuals with OCD compared to non-OCD controls. We (Abramowitz &
Foa, 1998) found that 20% of the DSM–IV OCD field study sample (n = 381)
also had a concurrent diagnosis of GAD. Two studies examined the rates of
various proposed OCD spectrum disorders among individuals with OCD. As
Table 1.7 indicates, with the exception of somatoform disorders
(hypochondriasis and body dysmorphic disorder), the proposed spectrum
disorders only rarely occur among OCD patients. The relationship between
OCD and proposed spectrum disorders is discussed further in chapter 2.
A number of studies have reported the prevalence of personality disor-
ders among individuals with OCD (e.g., Black, Noyes, Pfohl, Goldstein, &
Blum, 1993; Crino & Andrews, 1996b; Steketee et al., 1999). Estimates of
comorbidity with at least one personality disorder vary widely (from
8.7%–87.5%) depending on the methodology used to assess Axis II psych-
opathology. However, studies generally agree that personality disorders
belonging to the anxious cluster (e.g., obsessive–compulsive, avoidant) are
more common than those of other clusters.
TABLE 1.6
Percentages of OCD Patients With Other Anxiety Disorders
Crino & Andrews Antony et al. Nestadt et al.

a b
(1996a) (1998) (2001)a
Anxiety Disorder (N = 108) (N = 87) (N = 80)
Social phobia 42 41.4 36.0
Specific phobia — 20.7 30.7
Panic disorder 54 11.5 20.8
Agoraphobia — — 16.7
Generalized anxiety disorder 41 11.5 13.0
a
Concurrent diagnosis.
b
Lifetime comorbidity rate.
TABLE 1.7
Percentages of OCD Patients With Proposed
Obsessive–Compulsive Spectrum Disordersa
Jaisoorya et al. Nestadt et al.

(2003) (2001)
Proposed Spectrum Disorder (N = 231) (N = 80)
Somatoform disorders
Hypochondriasis 13 15
Body dysmorphic disorder 3 16
Impulse control disorders
Trichotillomania 3 4
Sexual compulsions 0.4 —
Compulsive buying 0.4
Kleptomania 0 3
Pyromania — 0
Pathological gambling 0 0
Eating disorders
Anorexia nervosa 0.4 9
Bulimia nervosa 0 4
Neurological disorders
Tourette’s syndrome 3 —
a
Lifetime comorbidity rates.
36
2
Differential Diagnosis:
What Is OCD and What Is Not?
The clinical picture of OCD presented in chapter 1 characterizes a specific

and unmistakable pattern of thinking and behavior. Obsessions are un-
wanted, unacceptable, and intrusive repetitive thoughts, ideas, images,
urges, or doubts that give rise to affective distress—typically in the form of
anxiety over some feared consequence(s). For example, the sufferer doubts
whether germs are present or whether he or she has made (or will make) a
catastrophic mistake. In response to the obsessional distress, individuals
with OCD deploy various safety-seeking strategies, some of which could
be regarded as compulsive, to reduce uncertainty over the perceived risk of
negative consequences. These strategies may take the form of overt, stereo-
typed, repetitive rituals such as checking to prevent a possible threat or
washing to remove an existing one. However, they may also be subtle, brief,
covert, and unobservable.
Gaining widespread acceptance is the notion that a number of psycho-
logical and neuropsychiatric disorders from various DSM diagnostic cate-
gories are related to OCD. Collectively, these conditions have been referred
to as obsessive–compulsive spectrum disorders (OCSDs). Some authors have
proposed, largely on the basis of clinical observation, that the OCSDs are
linked by shared clinical features (i.e., repetitive thoughts and behaviors),
courses of illness, family history, comorbidity, and treatment response
37
38 CHAPTER 2
(Hollander & Wong, 2000). Its intuitive appeal and popularity aside, the
OCSD concept has conceptual and practical difficulties. As we will see in
this chapter, although OCD and the OCSDs have some overlaps in symp-
tom presentation, not all OCSDs are characterized by the kind of phenom-
enology that is present in OCD. Clinicians working with individuals with
OCD must therefore be able to differentiate OCD phenomenology from
that which is distinct. After placing current conceptualizations of OCD
within a historical context, this chapter closely examines the clinical phe-
nomenology of some of the proposed spectrum conditions.
APPROACHES TO OCD THROUGH HISTORY
The earliest accounts of OCD were rooted in a religious context. Demons

were thought to possess people who complained of repetitive, unwanted
distressing thoughts, and who exhibited compulsive behavior. Treatment
usually entailed exorcism. The first nonreligious explanations held that ob-
sessions and compulsions developed from “psychic fatigue” in which an
individual’s mental and behavioral dyscontrol was caused by an imbal-
ance of “mental energy” (Janet, 1903). The psychoanalytic point of view
held that obsessions were unconscious impulses, and compulsions were
ego defenses against these impulses (Salzman & Thaler, 1981). Although
unsubstantiated by research, these early conceptualizations represented at-
tempts to understand the phenomenology of OCD.
The behavioral approach followed in the tradition of emphasizing
phenomenological mechanisms, yet advanced the methodology for do-
ing so by applying functional analysis, which clarified observable (and
therefore measurable) antecedents and consequences of obsessions and
compulsions (e.g., Dollard & Miller, 1950; Mowrer, 1960; Rachman &
Hodgson, 1980). Behavioral (learning) models of OCD propose that ob-
sessions develop as classically conditioned fear responses to previously
neutral stimuli. Compulsions are conceptualized as escape responses
that are negatively reinforced by the reduction in obsessional anxiety
that they engender. Most recently, the cognitive-behavioral approach,
discussed in the chapters that follow, has expanded the study of obses-
sive–compulsive phenomenology to maladaptive beliefs and assump-
tions thought to underlie obsessional fear (Salkovskis, 1985, 1989).
Strengths of both the behavioral and cognitive-behavioral approaches
are that they are derived from a vast clinical and laboratory research
base, and therefore are probably accurate.
Unfortunately, theoretically driven approaches to understanding the
complex phenomenology of OCD are all but abandoned in current diag-
nostic schemes, such as the DSM, which promote an understanding of dis-
orders as merely lists of signs and symptoms. With this shift toward a
DIFFERENTIAL DIAGNOSIS 39
reductionistic medical model, an appreciation for psychological mecha-

nisms (e.g., learning and cognitive mediation) is replaced by a more super-
ficial “checklist” approach that merely collects signs and symptoms
according to their form or topography, as opposed to their function. For ex-
ample, a complete understanding of safety behaviors as efforts to mitigate
obsessional distress that paradoxically strengthen obsessions is lost in the
DSM’s definition of compulsions as described in chapter 1. Thus, recogni-
tion of the rich phenomenology of OCD is diminished in favor of a more
cursory view of the disorder as characterized by the presence of repetitive
thoughts and behavior.
Perhaps a main cause of the shift in emphasis toward identifying overt
signs and symptoms of mental disorders was the desire to improve on the
poor diagnostic reliability of early versions of the DSM. However, this has
led to a blurring of the distinction between the symptoms of OCD and those
of various other disorders that also involve repetitive thoughts or actions,
even in cases where clear phenomenological (functional) differences exist.
The OCSD approach provides the hallmark example: A dizzying array of
problems from across the DSM are all proposed to be related to OCD based
on the presence of irresistible repetitive impulses and actions (Hollander &
Wong, 2000). I argue that this has had deleterious effects. For example, it is
relatively common to see patients given a diagnosis of OCD when they
have problems such as repetitive skin picking, hair pulling, and compul-
sive sexual behavior, which are actually phenomenologically distinct from
OCD. Next I consider a number of disorders often confused with OCD in
this way. Pulling from research on these various conditions I evaluate the
extent to which each condition may be said to be related to OCD. Further, I
discuss methods for distinguishing these disorders from OCD.
IMPULSE CONTROL DISORDERS
Trichotillomania
Trichotillomania (TTM) provides an excellent example of how an emphasis

on lists of signs and symptoms can be misleading in differentiating OCD
from other disorders. The chief DSM–IV–TR diagnostic criteria for TTM in-
clude: (a) recurrent pulling of one’s hair resulting in noticeable hair loss; (b)
increase in tension immediately before pulling, or when attempting to re-
sist pulling; and (c) pleasure, gratification, or relief when pulling out the
hair (APA, 2000). Going by this list of features alone, TTM appears to share
characteristics with OCD, namely, repetitive, compulsive behaviors. How-
ever, despite some overlap in the way that these symptoms are described,
intrusive anxiety-evoking obsessional thoughts that occur in OCD are not
present in TTM. This is an important difference because, as we saw in chap-
40 CHAPTER 2
ter 1, obsessional fears and doubts evoke the compulsive behavior in OCD.
That is, patients with OCD wash compulsively to escape from fears of con-
tamination or illnesses, they repeat actions because of intrusive thoughts
that things must be “just right,” and they compulsively check to assure
themselves that danger has not (or will not) occur. In contrast, urges to pull
one’s own hair in TTM are precipitated by feelings of general tension, de-
pression, anger, boredom, frustration, indecision, or fatigue (Christensen,
Ristvedt, & Mackenzie, 1993; Stanley & Mouton, 1996). Moreover, the hair
pulling leads to pleasurable feelings, a phenomenon not reported by OCD
patients after completing compulsive rituals (Rachman & Hodgson, 1980;
Stanley, Swann, Bowers, & Davis, 1992).
Some shared characteristics between OCD and TTM that deserve men-
tion include that both are frequently comorbid with mood, anxiety, eating,
personality, and substance use disorders; both may involve embarrassment
due to their symptoms; and both may impact the sufferer’s functioning. Al-
though TTM tends to affect females more often than males, an earlier age of
onset seems to be more common for males, and this is similar to the demo-
graphic pattern found in OCD. Importantly, the characteristics just men-
tioned are present among many emotional disorders, not just OCD and
TTM. Therefore, the presence of these features does not suggest a specific
relationship between the two disorders. Thus, aside from the fact that hair
pulling in TTM can be described as compulsive, TTM and OCD actually
have little that is uniquely in common in terms of their phenomenology.
Nevertheless, the keys to differentiating these two disorders lie in a thor-
ough examination of the precursors (triggers) and aftereffects (conse-
quences) of the compulsive behavior. To this end, clinicians may find the
information provided in Table 2.1 helpful in making the distinction and
explaining this difference to patients.
Nonparaphilic Sexual Disorders

Sometimes referred to as sexual addictions, sexual compulsions, or hyper-
sexuality, nonparaphilic sexual disorders (NPSDs) are problems involving
repetitive sexual acts comprised of conventional, normative, or nondeviant
sexual thoughts or behavior that the person feels compelled or driven to
perform, often in an exploitative way, which may or may not cause distress
(Goldsmith et al., 1998). Examples include the incessant use of Internet por-
nography, frequent masturbation, and continuous sexual encounters with
prostitutes to the detriment of one’s marital relationship. Although NPSDs
are not DSM diagnoses, people for whom this pattern of behavior persists
for at least 6 months and interferes with functioning meet diagnostic crite-
ria for impulse-control disorder not otherwise specified.
Because repetitive thoughts of a sexual nature are observed in both
NPSDs and OCD, some have proposed that NPSDs are a variant of OCD and
TABLE 2.1
Differentiating Between Compulsive Behaviors in Trichotillomania and OCD
Question Trichotillomania OCD

What is the compulsive Hair pulling, including May take various forms
behavior? manipulating or biting (e.g., washing, checking,
and eating the hair etc.)
What triggers provoke Boredom, being alone, Obsessional thought or
the compulsive urges? general stress or tension, other specific fear cues
physical sensation (e.g., (e.g., knives, toilets)
scalp itches)
Are obsessions present? No Yes
What is the outcome of General stress relief, Escape from specific
the compulsive behavior? relaxation, feels good obsessional anxiety,
reassurance
What time of day do the Often only at night Night or day
compulsive behaviors
occur?
therefore OCSDs (e.g., Hollander & Wong, 2000). To examine this proposal
empirically, my colleague Stefanie Schwartz and I conducted careful inter-
views with individuals with NPSDs and others with OCD who reported
“sexual obsessions” (Schwartz & Abramowitz, 2003). As Fig. 2.1 shows,
there were considerable differences in the phenomenology of the repetitive
thoughts and behaviors reported by people with these two conditions. Pa-
tients with OCD reported more fear and avoidance related to sexual
thoughts than did those with NPSDs. Conversely, individuals with NPSDs
evidenced greater sexual arousal associated with repetitive thoughts and be-
haviors compared to those with OCD. This is consistent with clinical obser-
vations that logging onto Internet chat rooms, for example, is not aimed at
reducing uncertainty or the probability of feared outcomes. Instead, these
sexual habits appear to be motivated by the physically and emotionally en-
joyable states they produce (e.g., sexual arousal, orgasm). This impulsive be-
havior is phenomenologically distinct from compulsive behaviors in OCD,
which the individual feels driven to perform to reduce anxiety or fear, and
which do not involve actual sexual activities.
The fact that both NPSDs and OCD involve repetitive sexual thoughts
can be a source of confusion in distinguishing between the two conditions.
As is described above, the clinician must carefully assess the antecedents
and consequences of such thoughts to determine whether the thought is an
obsession as in OCD, or a sexual fantasy as in NPSDs. The following exam-
ples illustrate this distinction.
42 CHAPTER 2
FIG. 2.1. Phenomenological characteristics of repetitive thoughts and behav-

iors in OCD and nonparaphilic sexual disorders. Adapted from “Are Non-
paraphilic Sexual Addictions a Variant of Obsessive-Compulsive Disorder: A
Pilot Study,” by S. Schwartz and J. Abramowitz, 2003, Cognitive and Behavioral
Practice, 10, pp. 372–377. Copyright 2003 by the Association for Advancement
of Behavior Therapy. Adapted with permission.
OCD patient:
Howard, who had been married to the same woman for 14 years, presented
with severe sexual obsessions as his primary OCD symptom. Whenever he
saw an attractive woman, Howard experienced recurrent images about what
she might look like without her clothes on. The thoughts were utterly repug-
nant to Howard and he perceived them as immoral and inconsistent with his
strong love and attraction to his wife. He did not want to think about or have
sex with these other women, they did not sexually arouse him, and he en-
gaged in attempts to “cancel out” or control the unwanted images whenever
they came to mind using strategies such as thought suppression. Howard was
afraid that if he could not control his sexual thoughts it meant that he was an
unfaithful husband and an adulterer. Thus, he tried to avoid places where
there might be many women (e.g., shopping malls, the health club) and con-
fessed his unwanted thoughts to his wife just to be sure she would stop him if
he began to act on them.
NPSD patient:
Robert, an accountant who had been married for 5 years, described often
thinking about attractive females he had seen recently. He imagined what
such women looked like undressed or wearing only their underwear, some-
times spending hours each day with such thoughts in his mind. These images
were highly sexually arousing to Robert and they often led to erections and
the urge to masturbate. Robert engaged in daily masturbation sessions dur-
ing which he purposely conjured up sexual images involving women he had
seen in places such as shopping malls or health clubs. Currently, he was mas-
turbating in the bathroom at work for up to 30 minutes at a time and this was
interfering with his productivity and his desire to have sex with his wife, who
had become upset with Robert’s behavior.
These two case examples portray the key phenomenological differ-

ences between sexual thoughts and repetitive behavior in OCD and
NPSDs. In OCD, sexual thoughts (i.e., obsessions) are perceived as unac-
ceptable and they lead to anxiety, avoidance, and urges to neutralize or
control the thought, or prevent feared consequences. People with OCD
are exquisitely sensitive to the potential for harm and it is this that makes
the occurrence of unwanted sexual thoughts especially unacceptable. In
contrast, for the person with NPSD, the sexual thought itself is not experi-
enced as distressing. In fact, it may be intentionally conjured up on a re-
peated basis because it is associated with sexual excitement or release. In
addition, such thoughts often lead to sexual behavior and devaluation of
the object of the thought (e.g., members of the opposite sex) in NPSDs, but
not in OCD. Although both OCD and NPSDs involve repetitive thinking
or behavior concerning sex, the underlying functional aspects of these
signs and symptoms suggest clear differences between the two disorders
in how these symptoms are experienced.
Kleptomania
Kleptomania involves the failure to resist urges to steal objects that are not
needed for personal use or monetary value (APA, 2000). Often referred to as
compulsive, the stealing behavior is actually impulsive as it occurs without
extensive planning. Moreover, the stolen items are typically of little value
and might never be used. People with kleptomania report no obsessional
fear or anxiety before stealing, but may describe a sense of general tension.
Also unlike in OCD, people with kleptomania report a “rush,” “thrill,” or
“manic high” associated with their stealing (McElroy, Keck, & Phillips.,
1995). Thus, the function of compulsive stealing in kleptomania is quite dif-
ferent from that of compulsive rituals and neutralizing in OCD. This impor-
tant phenomenological distinction leads to the conclusion that
kleptomania is not related to OCD.
Pathological Gambling
The essential features of pathological gambling include a preoccupation

with gambling; the need to gamble with increasing amounts of money to
44 CHAPTER 2
achieve the desired excitement; unsuccessful efforts to curtail the gambling

behavior; and a history of lying, fraud, theft, and relationship problems as-
sociated with gambling (APA, 2000). The gambling often occurs on a repeti-
tive basis, hence the proposed relationship to OCD. However, whereas
obsessional preoccupations in OCD are unwanted, unacceptable, resisted,
and lead to anxiety or fear, the thoughts about gambling evoke feelings of
excitement. Moreover, patients with pathological gambling report pleasure
or gratification during and after gambling (Hollander & Wong, 1995),
which is in contrast to compulsive behavior in OCD that serves to reduce
anxiety about feared outcomes. Thus, the drive to gamble, and the emotion
associated with this experience, is qualitatively different from that which is
present in OCD.
Compulsive Buying
Characterized by repeated, excessive, and inappropriate spending, and fre-

quent thoughts about shopping and buying, compulsive buying is not offi-
cially recognized as a mental disorder. This behavior, however, is
considered to fall in the category of impulse-control disorder not otherwise
specified. In contrast to obsessions and compulsions in OCD, preoccupa-
tion with buying and urges to make purchases are neither anxiety evoking
nor typically resisted, and the actual purchasing behavior is experienced as
gratifying and pleasurable (until long-term negative financial conse-
quences occur; McElroy et al., 1995). Thus, as with other impulse-control
conditions, the repetitive symptoms of compulsive buying are mediated by
vastly different psychological mechanisms than are compulsions in OCD.
Compulsive Skin Picking and Nail Biting
Parallels have been drawn between OCD and compulsive skin picking and
nail biting because these all involve senseless, repetitive behavior (Hol-
lander & Wong, 2000). However, as we have seen with the repetitious activ-
ity associated with other impulse-control problems, skin picking and nail
biting are performed in response to general tension rather than in response
to specific obsessional fears. Additionally, these habits are often associated
with gratification and tension relief, as opposed to escape and avoidance of
disastrous consequences. From a behavioral analytic perspective, repeti-
tive behavior in impulse-control disorders is primarily positively rein-
forced by its consequences (i.e., gratification). In OCD, however,
compulsive behavior is maintained by a process of negative reinforcement
(i.e., escape). Thus, the drive to pick one’s skin and bite one’s nails, and the
emotional experiences associated with these behaviors, are qualitatively
different from those present in OCD, even if they are all repetitious. Table
2.2 compares the antecedents and consequences of repetitive behaviors ob-
served in OCD and in impulse-control disorders.
TABLE 2.2
Comparison of Repetitive Behaviors in OCD and in Impulse-Control
Disorders Included in the OC Spectrum
OCD Impulse-Control Disorders

Antecedents • Specific fears of unde- • General tension, sexual
sirable consequences arousal, depression,
being alone, boredom,
• Unwanted, intrusive indecision, fatigue,
obsessional thoughts, thoughts about the
doubts, images, and behavior, excitement
impulses (e.g., sexual)
Characteristics • Usually deliberate • May be deliberate or
of the behavior indiscriminant
• May or may not be • May or may not be
repeated repeated
• May be carried out • Often performed by
by a proxy oneself
• Usually intended to • May be damaging or
reduce the chances of hurtful to self or others
harm
• May involve avoidance, • Typically overt
covert ritualizing, or
neutralization
• Typically resisted • Typically not resisted
(at least early in the
disorder’s course)
Consequences • Short-term escape • Emotional arousal;
from (or avoidance of) manic-like high,
obsessional distress pleasure, gratification,
or satisfaction
46 CHAPTER 2
TICS AND TOURETTE’S SYNDROME
Tics are involuntary, rapid, repetitive, and stereotyped movements of indi-

vidual muscle groups (APA, 2000). Characterized as motor or vocal and ei-
ther simple or complex, tics are easier to recognize than they are to precisely
define. Urges to perform tics can sometimes be resisted, but usually only
for a matter of minutes or seconds. Table 2.3 presents characteristics of vari-
ous classes of tics. Tourette’s syndrome (TS) is a neurological disorder in-
volving chronic and persistent motor and vocal tics that occur daily and
result in functional impairment. Some have likened tics to compulsions
(and therefore view TS as related to OCD) because both are repetitive, ste-
reotyped, and seem senseless (Hollander & Wong, 2000). Others have re-
ported a high prevalence of OCD symptoms (i.e., compulsions) among
samples of patients with TS and other tic disorders (e.g., Pauls, Towbin,
Leckman, Zahner, & Cohen, 1986), suggesting an apparent overlap.
On the other hand, researchers have acknowledged that comor-
bidity estimates between tic disorders and OCD may be artificially in-
flated due to the difficulty in distinguishing (particularly complex)
motor tics from compulsions (e.g., Shapiro & Shapiro, 1992). Under-
standing and discriminating between the two phenomena requires
close attention to functional aspects (as opposed to the mere repeti-
tiveness) of the target behaviors (O’Connor, 2001). As described pre-
viously, compulsive rituals in OCD are not movements per se, but
rather purposeful responses to obsessional stimuli, and there is the
sense that feared consequences may occur if the compulsive ritual is
not performed. In contrast, tics are spontaneous movements devoid
of purpose. Unlike compulsions, which are evoked by obsessional
thoughts and affective states, tics are evoked by physical tension and
TABLE 2.3
Characteristics of Different Classes of Tics
Type of Tic
Behavior Simple Complex
Motor Fast, darting, and meaningless Stereotyped series of movements
(e.g., eye blinking, head shaking) that may appear purposeful
(e.g., clapping, touching people)
Vocal Meaningless sounds and noises Linguistically meaningful utter-
(e.g., barking, throat clearing) ances (e.g., words, phrases)
feelings of sensory incompleteness or insufficiency (Leckman et al.,

1995; Leckman et al., 1994). The person with tics experiences a premon-
itory urge that may be anatomically located, although not necessarily
present with every tic. People with tics report a feeling of tension re-
lease after performing tics. Although TS and OCD share some superfi-
cial similarities, assessment of the functional characteristics of tics
and compulsions summarized in Table 2.4 suggests important differ-
ences between these symptoms.
SOMATOFORM DISORDERS
Hypochondriasis
Hypochondriasis (HC) is classified as a somatoform disorder in

DSM–IV–TR and is characterized by a preoccupation with fears of having
(or the conviction that one already has) a serious disease (e.g., cancer). The
fears are based on a catastrophic misinterpretation of benign bodily sensa-
tions (e.g., “This headache means I have a brain tumor”) and persist despite
appropriate medical evaluation and frequent reassurance from authorities
such as doctors or medical texts. The intrusive, incessant health-related
preoccupations in HC have been compared to obsessional thoughts or fears
in OCD; and the repetitive attempts to seek reassurance in HC have been
likened to compulsive checking rituals (Fallon, Javitch, Hollander, &
TABLE 2.4
Functional Characteristics of Tics and Compulsions
Characteristic Tics Compulsions

Antecedents Sensory tension; urge to Cognitive or affective
and triggers release energy distress (obsessional
thought, doubt, image,
impulse)
Description Spontaneous movements Purposeful responses
of the behavior with no apparent meaning to a perceived threat
Outcome Release of physical tension Escape or avoidance of
of the behavior feared consequences;
reduction in anxiety or
distress
If resisted Difficult if not impossible to Mounting autonomic
resist completely; can be anxiety symptoms; fear
delayed momentarily with effort of catastrophes
48 CHAPTER 2
Liebowitz, 1991). Research findings suggest functional similarities as well:

affective states (e.g., anxiety and depression) and the degree of resistance to
obsessional phenomena in HC are comparable to those in OCD (Neziroglu
et al. 2000). However, as a group, individuals with HC present with a less
diverse range of obsessional themes (i.e., they are restricted to somatic con-
cerns) and show less insight into the senselessness of their fears compared
to those with OCD (Abramowitz et al., 1999; Neziroglu et al., 2000).
Fine-grained functional analyses of HC symptoms (e.g., Abramowitz,
Schwartz, & Whiteside, 2002; Warwick & Salkovskis, 1990) also point to
similarities with OCD. Intrusive thoughts about illness in HC are associ-
ated with perceived threat and evocation of subjective anxiety as are obses-
sions in OCD. Repetitive checking behavior in HC is performed in response
to intrusive stimuli and function as a means of acquiring reassurance about
health status in a way that reduces distress, at least in the short term. Thus,
checking in HC serves as an escape from preoccupation with disease much
as compulsive rituals in OCD (e.g., washing, checking) serve as an escape
from obsessional anxiety (e.g., concerning germs, danger). Although classi-
fied as a somatoform disorder because of the focus on bodily concerns, HC
appears to feature signs and symptoms that are comparable in both form
and function with those in OCD, as reviewed in Table 2.5. Some authors
have recast hypochondriasis as “health anxiety disorder” (Taylor &
Asmundson, 2004).
Body Dysmorphic Disorder
Another somatoform disorder with features similar to OCD is body

dysmorphic disorder (BDD). BDD involves excessive preoccupation with
an imagined defect in appearance (e.g, “my nose is off-center”). Thoughts
of unsightliness occur in the absence of any noticeable physical defect, are
often resisted, and lead to significant anxiety about how the person appears
to others. In this way, preoccupations in BDD are functionally similar to ob-
sessions in OCD (Neziroglu & Yaryura-Tobias, 1993). To circumvent antici-
pated embarrassment, individuals with BDD may avoid particular social
situations or engage in behaviors that are aimed to reduce distress or the
visibility of their imagined defect. Examples include excessive checking in
mirrors, grooming, hiding the perceived defect, and comparing one’s body
with others’ bodies (Rosen, 1996; Veale & Riley, 2001). These behaviors bear
functional similarities to safety-seeking behaviors, such as compulsive rit-
uals, in OCD; namely, both are performed as a means of escape from anxi-
ety or threat when no actual danger is present. Although BDD appears to
involve similar levels of general anxiety and depression as OCD, people
Table 2.5
Comparison of Symptoms in OCD, Hypochondriasis, and BDD
Characteristic OCD Hypochondriasis BDD

Focus of intrusive Variable (aggres- Possible illnesses Imagined physical
thoughts or fears sion, sex, religious, defect and others’
contamination) perceptions
Emotion associated Anxiety Anxiety Anxiety
with intrusive
thoughts
Response to intru- Variety of overt or Check with doctors, Check mirrors, com-
sive thoughts covert neutralizing medical resources, pare oneself to
and compulsive friends or family, others, camouflage,
behaviors and own body; avoid- grooming, cosmetic
avoidance ance of fear cues surgery; avoid
interactions
Meaning of the Escape from anxiety Gain certainty or Examine extent of
response or distress, avoid reassurance about “disfigurement,”
feared health status gain certainty about
disasters appearance
Short-term outcome Anxiety reduction Anxiety reduction Anxiety reduction
of the response or increase
Long-term outcome Persistence of Health anxiety Fear of negative
of the response obsessional fear persists evaluation persists
with BDD seem to be singly obsessed with their imagined defect whereas
obsessional themes in OCD vary more widely (McKay et al., 1997). Table 2.5
also compares the symptoms of OCD and BDD on a functional level.
GENERALIZED ANXIETY DISORDER
The main features of GAD include chronic, exaggerated worry and tension
that is unfounded or much more severe than the normal anxiety that most
people experience. People with GAD are unable to relax and often suffer
from insomnia and other physical symptoms including fatigue, trembling,
muscle tension, headaches, irritability, and hot flashes.
Worries in GAD can be intrusive, unwanted, repetitive, and highly dis-
tressing to the individual. Therefore it is common for the worrying symp-
toms of GAD to be mistaken for obsessions as in OCD. The clinician should
therefore be aware of the differences between worries and obsessions,
shown in Table 2.6. First, whereas the content of worries in GAD is focused
50 CHAPTER 2
TABLE 2.6
Distinguishing Characteristics of Obsessions and Worry
Characteristic Obsessions Worry

Focus Bizarre, not everyday concerns Real-life circumstances
(e.g., serious illness from touching (e.g., finances, relation-
surfaces, unknowingly hitting a ships, health)
pedestrian)
Form Images, impulses, ideas, urges, Thoughts, doubts
thoughts, doubts (verbal content)
Content Improbable negative outcomes Generally pessimistic and
Stable or “fixed” content ruminative
Content often shifts
Resistance Strongly resisted, evoke neutral- Often ego-syntonic, little or
izing responses and safety no neutralizing responses
behaviors
on real-life circumstances such as finances, social and family relationships,

work, and school performance, obsessional content in OCD is typically
somewhat bizarre and does not concern actual life problems. Second, wor-
ries tend to involve verbal content, whereas obsessions often involve imag-
ery and impulses along with thoughts and doubts. Third, worry is often
ruminative with general pessimistic ideas about oneself, the world, and the
future that frequently shift in content from one topic to another. In contrast,
obsessions are typically stable (fixed) and concern improbable disastrous
consequences. Finally, whereas obsessions elicit neutralizing responses
such as compulsive rituals, worries and ruminations are not associated
with neutralizing.
OBSESSIVE–COMPULSIVE PERSONALITY DISORDER
It is unfortunate that OCD and OCPD share a similar name because these
problems have very little else in common. The main features of OCPD are an
enduring pattern of perfectionism, rigidity, stubbornness, and orderliness
that interferes with task completion; preoccupation with rules, organization,
and schedules so that the point of activities are lost; overconscientiousness
and inflexibility regarding ethical or moral issues (not accounted for by nor-
mal cultural or religious values); and excessive devotion to work and pro-
ductivity to the exclusion of friendships or leisure time (APA, 2000).
Although some of these characteristics are informally referred to as com-
pulsive and might be found among individuals with OCD, a closer exami-
nation reveals important differences in the cognitive mediation of these

symptoms. In OCD, compulsive or perfectionistic behavior is resisted. Al-
though the person wishes he or she did not feel compelled to behave this
way, the threat of disastrous consequences if he or she does not looms large
(e.g., “Things must be arranged alphabetically or else Mom and Dad’s
plane will crash”). In contrast, people with OCPD do not have obsessional
fears and instead perceive their compulsive traits as functional, agreeable,
and consistent with their worldview (i.e., ego syntonic). From a cognitive
perspective, people with OCPD appear to harbor core beliefs and assump-
tions such as, “Feelings, decisions, and behaviors are either morally right or
wrong,” “Making mistakes means I am bad, worthless, and a failure,” and
“Certainty and predictability are necessary to avoid mistakes; therefore I
must always be in control.” Whereas OCD symptoms are associated with
subjective resistance, individuals with OCPD do not resist thinking and
acting in this inflexible way and are often quite insurgent when it is sug-
gested that they adapt a less rigid style.
SCHIZOPHRENIA AND DELUSIONAL DISORDERS
It is important to distinguish psychotic disorders, such as schizophrenia,

and delusional disorders from OCD because these conditions possess cer-
tain superficial similarities that have led some to speculate a relationship
(e.g., Enright, 1996; Insel & Akiskal, 1986). In particular, both OCD and psy-
chotic disorders may involve repetitive, intrusive, highly fixed beliefs with
bizarre, absurd, and unwanted content (i.e., delusions in psychosis, obses-
sions with poor insight [overvalued ideas] in OCD); for example, thoughts
about harming loved ones (e.g., babies). Strange behavioral and mental rit-
uals, such as repeating routine activities, may also accompany both condi-
tions. Yet despite superficial similarities in how these symptoms are
described, substantial differences exist in their phenomenology and in how
they are experienced as discussed next and summarized in Table 2.7.
Primarily, people with psychotic disorders do not resist their bizarre, in-
trusive, unwanted thoughts. Moreover, such thoughts do not produce anxi-
ety or give rise to safety-seeking behavior. Instead, patients with delusional
problems typically distort reality to conform to their bizarre belief systems.
In contrast, obsessions in OCD are resisted, experienced as anxiety evok-
ing, and elicit urges to perform safety behaviors. Other differences include
that the senseless repetitive behavior in schizophrenia and other psychotic
disorders is truly pointless; its purpose cannot be explained by the person.
In contrast, even seemingly bizarre, extensive compulsive rituals and
avoidance behavior in OCD are purposeful and grounded in the sufferer’s
reality. That is, the sufferer can typically explain why he or she performs
52 CHAPTER 2
TABLE 2.7
Distinguishing Characteristics of OCD
and Psychotic and Delusional Disorders
Characteristic Obsessions Delusions

Resistance to Obsessions are strongly Delusions do not evoke anxi-
intrusive resisted. They evoke ety or distress. They are not
thoughts neutralizing responses resisted or neutralized. The
and safety behaviors. person might distort reality
to conform to the delusion.
Repetitive Safety-seeking maneuvers Pointless behavior. The
behavior performed to reduce obses- individual cannot explain
sional fear. The patient can its purpose.
explain the purpose of rituals.
Other features Individuals with OCD do not Other signs of severe mental
display other signs of psy- illness might be present (e.g.,
chosis (e.g., loosening associa- reduced self-care, poverty of
tions, negative symptoms). speech, flat affect).
safety behaviors, even if the explanation is based on miscalculations of risk,

misinterpretations of thoughts, and irrational fears. Finally, negative symp-
toms (e.g., loose associations, flat affect, poverty of speech) often present in
schizophrenia are not found in people with OCD.
OBSESSIONS VERSUS SOCIOPATHY
When violent obsessions are encountered, it is important to establish that

the obsession is part of OCD and not an indicator of antisocial tendencies.
Although one cannot predict with absolute certainty whether a person
will act on violent thoughts at some point in the future, clinicians can at-
tain an acceptable level of confidence by assessing whether or not the ob-
sessions are ego-syntonic or ego-dystonic. People who engage in anti-
social or sociopathic behavior experience their violent thoughts as ego-
syntonic (i.e., they are welcomed). They have histories of acting on
thoughts about committing actions. They also voluntarily generate fanta-
sies about committing such behaviors, seek out situations in which such
thoughts could be acted out, and devalue the victims (or potential vic-
tims) of such acts. In contrast, people with OCD experience such thoughts
as ego-dystonic and distressing. Such patients worry not only that they
might harm others, but that the mere occurrence of thoughts about vio-
lence indicates something personally abhorrent. This demonstrates their
sincere respect for others. Avoidance behavior, neutralizing, and thought

suppression are aimed at stopping the thought and reducing the per-
ceived chances that they might impulsively act on such thoughts. Because
an individual’s past behavior is the best predictor of his or her future be-
havior, one way a clinician can assess the probability that someone will act
on his or her violent thoughts is to find out about his or her history (e.g.,
“What’s the most violent thing you’ve ever done?”)
3
What Causes OCD?
In this chapter we explore three of the leading hypotheses proposed to ac-

count for the development of OCD: neuropsychiatric models, cognitive
deficit models, and the cognitive-behavioral perspective.1 In addition to
describing the central tenets of each theory, I review the relevant research
and provide critical remarks. As of yet, there is no definitive answer to the
question of what causes OCD. However, it is important to consider that
from the perspective of cognitive-behavioral therapy, the causes of OCD
are less important than are the factors that maintain the problem. Indeed
the aim of treatment is to reverse such maintenance processes. In chapter 4
we will see that despite a lack of clarity regarding the causes of OCD, sig-
nificant advances have been made in understanding how obsessional
symptoms are maintained.
1
A psychoanalytic model of OCD exists, yet as psychoanalytic theories in general
have largely been discredited in recent years (e.g., Eysenck, 1985) there is little need to
deal with it here. The theory contributes trivially, if at all, to the current understanding of
OCD and its treatment. Moreover, as is true for most of psychoanalysis, it has met its de-
mise largely due to the lack of recent contributions and its failure to demonstrate thera-
peutic effectiveness.
54
WHAT CAUSES OCD? 55
NEUROPSYCHIATRIC MODELS
The Serotonin Hypothesis
Biologically inclined theorists have proposed that neurochemical and neuro-
anatomical abnormalities are implicated in the development of OCD. The
leading neurochemical theory posits that OCD symptoms are caused by ab-
normalities in the serotonin system. In particular, Zohar and Insel (1987)
pointed to the hypersensitivity of postsynaptic serotonergic receptors.
Rosenberg and Keshavan (1998) also proposed that glutamate–serotonin in-
teractions underlie the disorder. Three lines of evidence are proposed to sup-
port the serotonin hypothesis of OCD: medication outcome studies,
biological marker studies, and challenge studies in which OCD symptoms
are evoked using serotonin agonists and antagonists. The most consistent
findings come from the pharmacotherapy literature, which suggests that se-
rotonin reuptake inhibitor medications (SRIs; e.g., fluoxetine, sertraline,
escitalopram) are more effective than medications with other mechanisms of
action (e.g., desipramine, imipramine) in reducing OCD symptoms (e.g.,
Abramowitz, 1997). In contrast, studies of biological markers, such as blood
and cerebrospinal fluid levels of serotonin metabolites, have provided incon-
clusive results regarding a relationship between serotonin and OCD (e.g.,
Insel, Mueller, Alterman, Linnoila, & Murphy, 1985). Similarly, results from
studies using the pharmacological challenge paradigm are largely incom-
patible with the serotonin hypothesis (e.g., Hollander et al., 1992)
There is some skepticism regarding the exact mechanism of action of the
SRIs. For example, because neurotransmitter systems do not work in isola-
tion, serotonergic neurons in one area of the brain may have synaptic rela-
tionships with, say, dopaminergic neurons elsewhere in the brain.
Therefore, increasing serotonin levels in one region (e.g., by administration
of SRIs) may effectively increase or decrease (depending on the relation-
ship) dopamine levels elsewhere. Ironically, one of the great scientific, as
opposed to practical, problems with the SRI drugs is that they seem to work
for such a wide variety of disorders. The fact that OCD responds to SRIs but
not to other types of antidepressant medicine is not, by itself, convincing
evidence that serotonin reuptake inhibition is the key to symptom im-
provement, or that serotonin is the culprit in OCD.
Neuroanatomy
Prevailing neuroanatomical models of OCD hypothesize that obsessions
and compulsions are caused by structural and functional abnormalities in
56 CHAPTER 3
particular areas of the brain, specifically, the orbitofrontal-subcortical circuits

(Saxena, Bota, & Brody, 2001). These circuits are thought to connect regions of
the brain involved in processing information with those involved in the initi-
ation of behavioral responses that are implemented with little conscious
awareness. The classical conceptualization of this circuitry consists of a di-
rect and an indirect pathway. The direct pathway projects from the cerebral
cortex to the striatum to the internal segment of the globus pallidus/substan-
tia nigra, pars reticulata complex, then to the thalamus and back to the cortex.
The indirect pathway is similar, but projects from the striatum to the external
segment of the globus pallidus to the subthalamic nucleus before returning
to the common pathway. In individuals with OCD, overactivity of the direct
circuit purportedly leads to OCD symptoms.
These structural models have largely been derived from the results of
neuroimaging studies in which activity levels in specific brain areas are
compared between people with and without OCD. Investigations using
positron emission tomography (PET) have found increased glucose utili-
zation in the orbitofrontal cortex (OFC), caudate, thalamus, prefrontal
cortex, and anterior cingulate among patients with OCD as compared to
nonpatients (e.g., Baxter et al., 1987; Baxter et al., 1988). Studies using sin-
gle photon emission computed tomography (SPECT) have reported de-
creased blood flow to the OFC, caudate, various areas of the cortex, and
thalamus in OCD patients as compared to nonpatients (e.g., Crespo-
Facorro et al., 1999). The fact that studies using PET and SPECT have
found differences between individuals with OCD and controls in the op-
posite directions is not necessarily contradictory, and probably arises be-
cause these methods measure different processes. Finally, studies
comparing individuals with OCD to healthy controls using magnetic res-
onance spectroscopy have reported decreased levels of various markers
of neuronal viability in the left and right striatum, and in the medial
thalamus (e.g., Ebert et al., 1997; Fitzgerald, Moore, Paulson, Stewart, &
Rosenberg, 2000). Although findings vary across studies, a meta-analysis
of 10 PET and SPECT studies found reliable differences in the orbital
gyrus and the head of the caudate nucleus between patients with OCD
and nonpatients (Whiteside, Port, & Abramowitz, 2004).
Limitations of Neurobiological Models
Neurobiological theories of OCD have a number of problems that should

be considered. First, they are contentless and provide little coherent ac-
count of the phenomenology of OCD—that is, they do not address the em-
pirically demonstrated relationships between obsessional fear and
compulsive behavior or neutralizing. Second, there is little correspondence
between the patterns of symptoms that patients report and the biological
WHAT CAUSES OCD? 57
mechanisms proposed to account for them. For example, no coherent ex-

planation has been offered to explain how neurotransmitter or neuroana-
tomical abnormalities translate into OCD symptoms (e.g., why does
hypersensitivity of postsynaptic receptors cause intrusive obsessional
thoughts, anxiety, compulsive rituals, or neutralizing?). Third, purely bio-
logical models are unable to account for the restriction of OCD symptoms
to particular types of stimuli. As Rachman (1997) noted, obsessions of caus-
ing harm to others invariably target the defenseless—the elderly, disabled,
and babies—whereas there are no “Arnold Schwartzenegger obsessions.”
That there are many stimuli about which OCD patients do not obsess sug-
gests that general biological deficits, if present at all, must interact with
learning and environmental factors in the etiology of OCD.
A fourth problem with biological models is the way that outcome data
from studies on the effects of SRIs have been interpreted. Because the sero-
tonin hypothesis originated from the findings of preferential efficacy of
clomipramine (an SRI) over nonserotonergic tricyclic antidepressants
(e.g., imipramine, desipramine; Zohar & Insel, 1987), the assertion that
the effectiveness of SRIs supports the serotonin hypothesis is circular.
Further still, models of etiology cannot be derived solely from knowledge
of successful treatment response. This is an example of the logical error
known as ex juvantibus reasoning, or reasoning backward from what
helps, which is a variation of the fallacy known as post hoc ergo propter hoc,
or after this, therefore because of this. The logical fallacy is clear if you con-
sider the following example: When I take aspirin, my headache goes
away. Thus, the reason I get headaches is because my aspirin level is too
low. Just as there may be many possible mechanisms by which aspirin
makes headaches go away, there may be many possible mechanisms by
which SRIs decrease OCD symptoms.
Of course, the serotonin hypothesis could be supported by evidence
from controlled studies demonstrating differences in serotonergic func-
tioning between individuals with and without OCD. Especially convincing
would be a demonstration that the administration of serotonin agonists
produces the onset (or exacerbation) of OCD symptoms. Yet the numerous
biological marker and pharmacological challenge studies that have been
conducted to date provide remarkably inconsistent results (for a review,
see Gross, Sasson, Chorpa, & Zohar, 1998). So, although it is likely that ob-
sessive–compulsive symptoms involve the serotonin system at some level
(one is hard-pressed to find many human processes that do not involve the
serotonin system), the existing evidence does not suggest that OCD is
caused by an abnormally functioning serotonin system.
A fifth problem is that results from brain scanning studies are not con-
vincing. For example, SPECT studies reporting differences in blood flow to
the OFC between OCD patients and nonpatients do not necessarily provide
58 CHAPTER 3
evidence for a neuroanatomical abnormality; nor do they implicate the

OFC as involved in the production of OCD symptoms. This is because such
correlational study designs cannot address whether true abnormalities ex-
ist (abnormal compared to what?), or whether observed associations are
even related to the causes of OCD. In fact, some data suggest that it is the act
of obsessing that causes changes in brain functioning (e.g., Cottraux et al.,
1996; Mataix-Cols et al., 2003). For instance, Cottraux et al. (1996) compared
PET scans of 10 patients with OCD with checking rituals while obsessing
and while resting to 10 nonpatients while thinking about normal obses-
sions and while resting. Results indicated that both groups showed in-
creased activity in the OFC during evocation of obsessional thoughts. In
another study, when patients with OCD received successful treatment,
there were corresponding decreases in OFC activity (Baxter et al., 1992).
Most recently, Mataix-Cols and colleagues (2003) found that the brain sys-
tems implicated in the mediation of anxiety in healthy study participants
are similar to those identified in OCD patients during symptom provoca-
tion. Moreover, anxiety associated with different OCD symptom dimen-
sions was associated with differential patterns of activation in these neural
systems. Taken together, data from brain scanning research in OCD seem to
be showing nothing more than neurophysiological, neuropsychological,
and biochemical correlates of normally functioning cognitive systems.
Summary
Neuropsychiatric models of OCD endorse the idea that the kinds of

thoughts and behaviors displayed by people with OCD are so strange that
they defy any explanation short of an appeal to disease processes. Yet
claims that OCD is caused by neuropsychiatric irregularities are prema-
ture. Ultimately, biological research may prove important in furthering our
understanding of OCD. As of yet, however, a comprehensive neuro-
biological theory that can be subjected to and can pass experimental scru-
tiny has yet to be clearly articulated.
COGNITIVE DEFICIT MODELS

Memory Deficits
On another level, some theorists have considered that OCD symptoms
might be caused by abnormally functioning cognitive processes, such as
memory. For example, perhaps compulsive checking arises as a conse-
quence of not being able to remember whether or not one has locked the
door, turned off the oven, or unplugged the iron. However, despite its intu-
itive appeal, this hypothesis has not received strong support (for a review
see Muller & Roberts, 2005). Savage et al. (1996) found evidence of im-
WHAT CAUSES OCD? 59
paired recall for nonverbal stimuli in OCD patients compared to

nonpatient controls, although this deficit was not found for verbal stimuli
or on recognition tasks. Other investigations have found no evidence of an
overall memory deficit among individuals with OCD (e.g., Abbruzzese,
Bellodi, Ferri, & Scarone, 1993; Tolin, Abramowitz, Brigidi et al., 2001).
In a meta-analysis of 22 studies (including 794 participants) on memory
in compulsive checking, Woods, Vevea, Chambless, and Bayen (2002)
found small to medium effect sizes, suggesting that compulsive checkers
do not perform quite as well as noncheckers on tests of short-term/work-
ing memory and episodic long-term memory. However, Woods et al. (2002)
also cautioned that mediating variables, such as self-doubt, could account
for the apparent memory deficits in checkers. For example, Clayton, Rich-
ards, and Edwards (1999) found that individuals with OCD performed
more poorly than healthy controls and individuals with panic disorder on
timed, but not on untimed tasks. This raises the possibility that excessive
caution or slowness in responding, rather than a memory deficit per se,
hindered performance.
Conceding largely equivocal evidence for an across-the-board memory
deficit, some theorists have proposed that individuals with OCD have mem-
ory problems only where their obsessional fears are concerned. This would
explain, for example, why a patient who fears burglaries might spend hours
rechecking that doors to the outside (e.g., the garage door) are securely
locked, yet have no urges to check closet or bathroom doors. However, re-
sults from the few studies that have examined this selective memory hypoth-
esis suggest just the opposite: Patients appear to have enhanced memory for
threat-relevant (OCD-related) information. In one study, Radomsky and
Rachman (1999) had healthy individuals and OCD patients with washing
compulsions look at everyday (neutral) objects, such as a ruler, that had been
touched with either a “clean” cloth or a “dirty” cloth. In a subsequent sur-
prise recall test, the OCD patients recalled more “contaminated” objects than
“clean” objects, and they recalled fewer “clean” objects than did the
nonpatient participants. Radomsky, Rachman, and Hammond (2001) repli-
cated their earlier findings in a study with compulsive checkers. Together,
these two studies strongly suggest that individuals with OCD have a selec-
tively better memory for anxiety-relevant events. Such a memory bias for
threatening stimuli is adaptive and can be conceptualized as part of the nor-
mal fight-or-flight response that functions to protect organisms from harm.
That is, paying attention to and being able to remember characteristics of
stimuli perceived to be harmful serves a protective function.
Reality Monitoring Deficits

If abnormal working memory per se does not underlie OCD, perhaps the
symptoms are caused by deficits in reality monitoring—the ability to dis-
60 CHAPTER 3
criminate between memories of actual and imagined events (Johnson &

Raye, 1981). It seems plausible that ritualistic checking, for example, is
prompted by problems discerning whether an action (e.g., locking the
door) was really carried out or merely imagined. However, studies examin-
ing the reality monitoring skills of OCD patients also report inconsistent re-
sults. Whereas two investigations (Ecker & Engelkamp, 1995; Rubinstein,
Peynircioglu, Chambless, & Pigott, 1993) found that OCD patients did not
discriminate between real and imagined actions as well as did healthy con-
trols, the majority suggest that OCD is not characterized by a deficit in real-
ity monitoring ability (Brown, Kosslyn, Breiter, Baer, & Jenike, 1994;
Constans, Foa, Franklin, & Matthews, 1995; Hermans, Martens, De Cort,
Pieters, & Eelen, 2003; McNally & Kohlbeck, 1993). In their meta-analytic
review, Woods et al. (2002) found virtually no differences in reality moni-
toring between OCD patients and control groups across five studies (effect
sizes = 0.02 and 0.03).
Inhibitory Deficits
The intrusive, repetitious, and seemingly uncontrollable quality of obses-

sional thoughts has led some researchers to hypothesize that OCD pa-
tients have deficits in their ability to dismiss or attend to extraneous
mental stimuli (i.e., cognitive inhibition). For example, Wilhelm,
McNally, Baer, and Florin (1996) used a directed forgetting procedure to
test whether OCD patients have a dysfunction in their ability to forget dis-
turbing material. In this study, OCD patients and healthy control partici-
pants were presented with a series of negative, positive, and neutral
words, and given instructions to either remember or to forget each word
after it was presented. Tests of recall and recognition showed that OCD
patients had more difficulty forgetting negative material relative to posi-
tive and neutral material, whereas control participants did not. Tolin,
Hamlin, and Foa (2002) replicated and extended this finding by demon-
strating that relevance to OCD, rather than threat relevance alone, pre-
dicted impaired forgetting.
Poor cognitive inhibition might lead to a greater frequency of intrusive
thoughts, making deliberate attempts to suppress such thoughts more dif-
ficult. The directed forgetting results reviewed earlier are complemented
by another study in which we gave participants with OCD, social phobia,
and healthy controls instructions to suppress thoughts of “bears,” and
measured how quickly they could recognize the word bear in comparison
with other words that had not been suppressed (Tolin, Abramowitz,
Przeworski, & Foa, 2002). We found that the individuals with OCD had
faster recognition times compared to the other groups, suggesting a deficit
in thought suppression ability in OCD.
WHAT CAUSES OCD? 61
Synthesis of Cognitive Deficit Research
It is easy to understand how one might reach the conclusion that OCD pa-
tients (especially those with compulsive checking symptoms) suffer from
general cognitive deficits such as memory or reality monitoring impair-
ments. However, the research findings reviewed thus far provide only
weak support for global memory problems in OCD. Interestingly, the
most consistent finding emerging from the research on memory and real-
ity monitoring in OCD is that compared to nonpatients, individuals with
OCD have less confidence in their own memory (e.g., Foa, Amir,
Gershuny, Molnar, & Kozak, 1997; MacDonald, Antony, MacLeod, &
Richter, 1997; McNally & Kohlbeck, 1993; Woods et al, 2002; for a review,
see Muller & Roberts, 2005). However, reduced confidence in one’s (nor-
mally functioning) memory is not a deficit per se; rather, it is an erroneous
interpretation (e.g., “I recall having locked the door, but I can’t trust that
my memory is accurate”). Interestingly, Radomsky et al. (2001) found that
reduced memory confidence was enhanced under conditions of experi-
mentally induced responsibility. Moreover, Tolin, Abramowitz, Brigidi,
Amir, Street, & Foa (2001) found that confidence in memory for threat-rel-
evant (but not irrelevant) stimuli declined over time. Thus, there is strong
evidence that compulsive checking results, at least in part, from decreased
memory confidence, particularly in situations where there is the percep-
tion of responsibility for mistakes.
Astutely, Radomsky and Rachman called attention to the difference be-
tween memory deficits and memory bias. They demonstrated that individuals
with OCD show normal overall memorial abilities, yet have a bias toward
remembering feared objects that is amplified in situations of heightened re-
sponsibility (Radomsky & Rachman, 1999; Radomsky et al., 2001). More-
over, feeling responsible was associated with reduced memory confidence.
These findings are consistent with research suggesting that increased
attentional and memorial resources are allocated to processing information
relevant to a person’s current emotional state (e.g., Kovacs & Beck, 1978). In
the case of anxiety, this is particularly adaptive and can be conceptualized
as part of the normal body’s normal response to perceived danger.
Radomsky and Rachman’s results are also consistent with the idea that,
fearing responsibility for negative outcomes, people with OCD become
highly concerned about their memory and try to compensate by checking.
This memory bias hypothesis is consistent with clinical observations.
One patient in our clinic described spending hours checking to make sure
she did not write curse words in notes she was sending to business col-
leagues, whereas she could send notes to close family members without
any checking. This common phenomenon would be difficult to explain as
a general problem with reduced memory or even as a deficit in memory
62 CHAPTER 3
confidence: Why is there better memory for notes being sent to some peo-
ple as opposed to others? More likely, the checking of only certain letters
results from feeling an increased sense of responsibility that (because of
the higher stakes) leads to reduced memory confidence in that particular
situation (Radomsky et al., 2001). A similar observation is how the pres-
ence of trusted others (e.g., therapist, spouse) reduces compulsive urges,
as in the patient who only checks that the garage door is closed when her
husband is away on business.
Interestingly, Radomsky and colleagues suggested a reconciliation
with previous research reporting apparent neuropsychological deficits in
OCD (e.g., Tallis, 1997). Given that individuals with OCD may be dis-
tracted by obsessional thinking, and may delay or withhold their re-
sponses due to uncertainty, it seems plausible that low scores on neuro-
psychological tests are secondary to OCD-related symptoms and not sim-
ply the result of actual memory problems. Therefore, research attempting
to understand the etiology of OCD by studying general cognitive and
neuropsychological deficits has two caveats. First, the results of such
studies are likely attributable to the effects of being anxious as opposed to
etiologically significant variables. Second, such research severely con-
founds salience of cues with etiological factors. For example, the fact that
patients have slower reaction times during neuropsychological tests is
easily attributable to their problems with indecision. This is not to say that
research on information processing in OCD is valueless; it may be highly
important in helping to understand the processes that maintain (rather
than cause) obsessions and compulsions.
Additional problems with cognitive deficit models include their inabil-
ity to explain the effectiveness of exposure and response prevention treat-
ment, their inability to account for the heterogeneity of OCD symptoms,
and the fact that mild neuropsychological deficits have been reported in a
number of mood, eating, and anxiety disorders (Alarcon, Libb, & Boll,
1994). All of this suggests that even if deficits such as poor memory func-
tioning or cognitive dyscontrol were involved at all in the production of ob-
sessions and compulsions, they likely are involved in a nonspecific way.
Summary
The idea that OCD arises from general cognitive deficits does not add to the
understanding of the disorder. Apparent memory and other processing
deficits are better accounted for by cognitive biases in which obsessional
anxiety leads to preferential processing of threat relevant stimuli. In the
case of compulsive checking, it is likely that reduced confidence in memory,
and therefore concern over whether the seeming memory problems will
lead to misfortune, are evoked by the perception that one may be (or may
WHAT CAUSES OCD? 63
come to be) responsible for negative outcomes. Hence, checking results as a

way of reducing doubts that have arisen because of mistaken beliefs about
one’s memory, ability to manage doubts and uncertainty, and pathological
estimates of responsibility for harm.
THE COGNITIVE-BEHAVIORAL MODEL
In contrast to the models already presented, which emphasize the presence

of biological or functional abnormalities, cognitive-behavioral models of
the development of OCD posit that obsessional symptoms develop from
essentially normal (albeit biased) thinking and learning processes. More-
over, the model emphasizes specificity in that it proposes that obsessional
problems arise from a pattern of idiosyncratic responses to key stimuli to
which the individual has become sensitive. Observations such as apparent
neuropsychiatric irregularities and memory problems are regarded as con-
sequences of the emotional arousal and counterproductive strategies the
sufferer uses to manage anxiety.
Obsessions and Compulsions Originate From Normal Experiences

Although it is an intuitively appealing hypothesis, the development of
OCD cannot be attributed to the mere presence of intrusive thoughts, ideas,
images, or impulses. This is because unwanted and senseless thoughts are a
universal experience (e.g., they occur in 80% of the general population;
Rachman & de Silva, 1978; Salkovskis & Harrison, 1984), yet the prevalence
of OCD is only about 2% to 3%. Even the presence of intrusions with highly
bizarre, upsetting, or unacceptable content does not predict who develops
OCD. Indeed, studies on unwanted thoughts indicate that so-called normal
obsessions closely resemble clinical obsessions in terms of their form and
content. In fact, Rachman and de Silva (1978) found that even experienced
mental health professionals had difficulty distinguishing the intrusive
thoughts of OCD patients from those of nonpatients. Patients and non-
patients alike reported unwanted impulses to attack or harm people they
were not upset with, thoughts about family members being harmed in acci-
dents, images of personally unacceptable or violent sexual acts, and ideas
of contamination. Subsequent work has consistently replicated Rachman
and de Silva’s initial findings (e.g., Abramowitz, Schwartz, & Moore, 2003;
Freeston, Ladouceur, Thibodeau, & Gagnon, 1991; Ladouceur et al., 2000;
Salkovskis & Harrison, 1984). Table 3.1 shows a sample of the kinds of in-
trusions reported by non-treatment-seeking individuals. The universality
of intrusive thoughts also applies to compulsive rituals. Over 50% of the
population exhibits ritualistic behavior in one form or another (Muris et al.,
1997), and 10% to 27% report significant compulsive behavior (e.g., Frost,
Lahart, Dugas, & Sher, 1988).
TABLE 3.1
Examples of Intrusive Thoughts Reported
by Nonclinical Individuals
Thought of catching a disease from a public swimming pool

Image of my home burning down and I lose everything I own
Impulse to blurt out curse words when everyone is praying silently in the synagogue
Idea of gouging my infant’s eyes out
Thought that I would be less likely to have a car accident if my brother had one
first
Thought of smashing a wine bottle over my frail father’s head
Thought that I didn’t lock the door before leaving the house
Impulse to shout racial slurs when in the company of minorities
Doubt about whether I wrote something inappropriate in an important e-mail
message
Idea of purposely poisoning my child by putting harmful substances in his milk
Idea that I will get sick from shaking hands in a receiving line
Thought about the baby’s genitals
Unwanted image of relatives having sexual intercourse
Doubts about whether I really have faith in God
Thought that I’d be able to do more social activities if the baby hadn’t been born
Idea that the baby has cerebral palsy
Imagining what it would be like if my wife died in a car accident
Impulse to throw the baby off the balcony
Idea that others think I am responsible for the workplace robbery that occurred
Image of the baby’s dead body lying in the crib
Idea of reaching for a police officer’s gun
Feeling “bad” for a toy that got broken
Thought that the room must be in perfect order before I leave
Idea of saying something very nasty that would ruin my boyfriend’s day
Thought of driving into oncoming traffic
Image of a patient dying because I made an error in their medical records
Image of the neighbor’s dog attacking the baby
Idea that the furnace or other electrical appliances will catch fire while I am not home
Note. List adapted from Rachman and de Silva (1978), Abramowitz, Schwartz, and Moore
(2003), and unpublished research.
64
WHAT CAUSES OCD? 65
There is good reason to think that life events, current concerns, and pres-
ent interests influence the occurrence and themes of intrusive thoughts. For
example, Horowitz and colleagues (e.g., Horowitz, 1975) found that expo-
sure to films with distressing content increased the incidence of intrusive
upsetting thoughts. Parkinson and Rachman (1980) reported increases in
unwanted thoughts among mothers of children who were about to have
surgery. Other authors have reported that OCD patients with trauma histo-
ries had obsessions related to their traumatic experiences (de Silva &
Marks, 1999). Accumulating evidence suggests that intrusive thoughts that
develop following the birth of a child (for both new mothers and fathers)
typically involve unwanted ideas of harming the baby or making terrible
mistakes regarding the infant’s care (e.g., Abramowitz et al., 2001;
Abramowitz, Schwartz, Moore, & Luenzmann, 2003). My colleagues and I
found that 69% of postpartum women and 58% of new fathers experience
intrusive distressing thoughts and impulses regarding their newborn in-
fant (Abramowitz, Schwartz, & Moore, 2003). These findings correspond
with clinical observations suggesting that external stimuli spark spontane-
ous intrusions. For example, some people report that just the sight of objects
that could be used to commit violence, such as knives, guns, scissors, or
wine bottles, provokes unwanted ideas or impulses about harm. Thus,
threatening intrusions may follow exposure to (or anticipation of)
threatening material, especially if one is sensitive to external danger signs.
Despite their similar content, the intrusive obsessional thoughts of OCD
patients differ from those of nonpatients along other parameters. People
with OCD experience their obsessions more frequently, for longer dura-
tion, and as more distressing and more difficult to control (Rachman & de
Silva, 1978). Thus, a viable causal theory of OCD must account for the fact
that while practically everyone experiences unwelcome intrusive, obses-
sional thoughts from time to time, only a small proportion of the popula-
tion develops clinically significant symptoms.
Misinterpretations and Other Dysfunctional

Cognitions Lead to Obsessions
Mindful of the fact that intrusive thoughts—even those about extremely

senseless, upsetting, vulgar, dirty, violent, disgusting, or blasphemous top-
ics—pose no realistic threat, most people confer little (if any) significance
on such intrusions and consequently do nothing about them. As a result,
such thoughts proceed harmlessly and unceremoniously in and out of con-
sciousness. However, Rachman (1976, 1993) and Salkovskis (1985, 1989)
proposed that if a person appraises such thoughts as highly significant or
threatening, the harmless intrusions will come to evoke distress and de-
velop into clinical obsessions. Salkovskis (1985, 1989) emphasized the role
66 CHAPTER 3
of responsibility appraisals, meaning that the individual interprets intrusive

thoughts as an indication that (a) harm to himself or herself or someone else
is particularly likely, and (b) the person may be responsible for such harm
(and for preventing the harm). Rachman (1997, 1998) later suggested that
misinterpretations of intrusive thoughts were not limited to responsibility
appraisals, but could be any interpretation of the occurrence or content of
the intrusion as personally significant, revealing, threatening, or cata-
strophic. For example, one might believe that the occurrence of the thought
“I could spread germs to my family and make them very sick” means that
there is a strong probability that this will happen unless something is done
to prevent it, such as avoidance, hand washing, or reassurance seeking.
Misinterpreting intrusive thoughts in this way evokes obsessional fear.
The idea that obsessional distress would result from misinterpreting
common intrusive thoughts as threatening draws on Beck’s (1976) cogni-
tive specificity model of emotion. The cognitive specificity model stipu-
lates that emotions are caused not by situations or stimuli per se, but rather
by how the person ascribes meaning to the situation or stimuli. Moreover,
particular emotions (and corresponding behaviors) are linked with specific
interpretations. For example, interpretations concerned with loss lead to
depression and crying, whereas the perception that one has deliberately
been treated with disrespect leads to anger and hostility. When an individ-
ual blames himself or herself for failing to achieve a goal, the result is guilt.
Interpretations concerned with perceived threat lead to anxiety and taking
action to reduce the perceived threat, as we observe in OCD.
As a clinical illustration let us consider the example of Becky, who re-
ported intrusive obsessional thoughts that her young children might acci-
dentally consume her medication and become terribly ill or die. As a result
of her fear, Becky spends hours each day checking the floors for lost pills
and recounting the pills in her containers. Essentially, Becky’s thoughts
about accidental deaths can be regarded as normally occurring stimuli.
Thus, it is not the occurrence or content of these thoughts per se, but rather
how Becky interprets their occurrence or content, that leads to obsessional
distress. In particular, Becky’s obsessional distress is caused by her errone-
ous beliefs that just because she has the intrusive thoughts, it means that a
negative outcome is likely and that she is responsible for preventing it. This
process is depicted in Fig. 3.1.
The cognitive-behavioral model also proposes that once intrusive
thoughts are misinterpreted as threatening, they naturally become the tar-
get of preoccupation (i.e., vigilance) and safety-seeking behavior such as
avoidance and compulsive rituals (e.g., Becky’s checking and counting).
These, as well as other processes, in turn maintain the threat value of the in-
trusions and give rise to a self-perpetuating cycle of obsessional distress
and safety-seeking behaviors that increase the vulnerability toward contin-
WHAT CAUSES OCD? 67
FIG. 3.1. The cognitive theory of emotion as applied to Becky’s intrusive

thoughts.
uing anxiety. The specific factors that maintain OCD symptoms are the
topic of chapter 4.
Misinterpreting intrusive mental stimuli, as well as external situations
and stimuli, as significant, threatening, and having implications for re-
sponsibility for harm (or the prevention of harm) appears to be linked to
more general dysfunctional beliefs and attitudes that people with OCD
hold. An international group of researchers, the Obsessive Compulsive
Cognitions Working Group (OCCWG), which has spearheaded the study
of cognition in OCD, has described six categories of dysfunctional beliefs.
These are summarized in Table 3.2 and discussed in detail next:
An Inflated Sense of Responsibility. Responsibility refers to the be-

lief that one has the pivotal power to cause or prevent particular unwanted
outcomes. Individuals with OCD often view themselves as responsible for
the content featured in their intrusive thoughts. They may be as concerned
about failing to prevent bad outcomes (sins of omission) as they are with di-
rectly causing them (sins of commission; Wroe & Salkovskis, 2000). Exces-
sive responsibility evokes feelings of anxiety and guilt.
Responsibility appraisals may be observed across the range of OCD
symptom dimensions. For example, a patient we evaluated described ob-
sessional thoughts of contaminating his family with germs from the funeral
home where he worked. He felt responsible for seeing to it that none of his
relatives became ill. Another individual reported obsessional thoughts of
people being injured and felt compelled to absolve himself of any responsi-
bility by excessively warning others (even strangers) of potential hazards
such as icy walkways, flat tires, and untied shoelaces.
The Overimportance of Thoughts. Individuals with OCD often rea-

son (erroneously) that the mere presence of unwanted intrusive thoughts
indicates that such thoughts are significant and meaningful. Thought–ac-
tion fusion (TAF) refers to two particular beliefs: (a) that intrusive
thoughts are morally equivalent to the corresponding actions (moral
68
TABLE 3.2
Domains of Dysfunctional Beliefs in OCD
Category Description
Excessive responsibility Belief that one has power to cause or the duty to prevent negative outcomes featured in intru-
sive thoughts
Overimportance of thoughts Belief that the mere presence of a thought indicates that the thought is significant
Moral TAF Belief that thoughts are morally equivalent to the corresponding action
Likelihood TAF Belief that thinking about an event makes the event more likely
Need to control thoughts Belief that complete control over one’s thoughts is both necessary and possible
Overestimation of threat Belief that negative events associated with intrusive thoughts are likely and would be insuffer-
able
Perfectionism Belief that mistakes and imperfection are intolerable
Intolerance for uncertainty Belief that it is necessary and possible to be 100% certain that negative outcomes will not occur
Note. TAF = thought–action fusion. From Cognitive Approaches to Obsessions and Compulsions: Theory, Research, and Treatment, by R. O. Frost & G. S.
Steketee (Eds.), 2002, New York: Pergamon. Copyright 2002 by Pergamon. Reprinted with permission.
WHAT CAUSES OCD? 69
TAF), and (b) that thinking about something makes the corresponding
event more likely (likelihood TAF; Shafran, Thordarson, & Rachman,
1996). For example, “It is just as immoral to think about cursing in church
or synagogue as it is to actually curse, and because I am thinking about
cursing, I will probably do it.” People with OCD also attach exaggerated
significance to intrusive unwanted thoughts by regarding them as repug-
nant, horrific, dangerous, disgusting, sinful, alarming, insane, or criminal
(Freeston, Ladouceur, Gagnon, & Thibodeau, 1993; Rachman, 2003).
Many patients believe their intrusive thoughts reveal important but hid-
den aspects of their personality or character, such as, “These thoughts
mean that deep down I am an evil, dangerous, and unstable person.” One
patient concluded, “Thinking about my parents having a car accident
means that I must really want this to happen.”
The Need to Control Unwanted Thoughts. Related to perceiving in-

trusive thoughts as important, individuals with OCD may believe that it is
both possible and necessary to maintain complete control over their un-
wanted thoughts (Purdon & Clark, 1994). A related assumption is that it is
important to track and “keep a look out” for intrusive or unwanted mental
events. Such beliefs are usually associated with repugnant obsessions con-
cerning aggression, violence, unwanted sexual themes, and blasphemous
or taboo subjects (religious or morality obsessions), and may be accompa-
nied by the fear that not controlling such thoughts will have disastrous
moral, behavioral, or psychological consequences. The resistance to obses-
sions that is commonly observed in OCD occurs as a result of such beliefs.
Overestimation of Threat. People with OCD tend to exaggerate the

probability and costs of negative events associated with their obsessions
(e.g., mistakes, sickness, or harm). Whereas most people take for granted
that a situation is safe unless there are clear signs of danger, those suffering
from OCD assume obsessional situations are dangerous or insufferable un-
less they have a guarantee of safety. For example, someone with contamina-
tion fears might exaggerate the probability of infection, as well as the
severity of the resulting illness. Those with fears of making errors may
overestimate the probability of discarding important information and the
negative consequences of such a mistake. Many patients also hold the belief
that anxiety itself will persist indefinitely and lead to physical or psycho-
logical damage. Overestimates of threat likely arise from anxious patients’
inaccuracies in judgment. Rather than using objective evidence, these indi-
viduals frequently rely on publicized cases or the content of obsessional
thoughts to make such predictions. Excellent examples include obsessional
fears of relatively rare conditions that often gain media attention such as
West Nile virus, SARS, or Lyme disease.
70 CHAPTER 3
Perfectionism. OCD is associated with an inability to tolerate mis-

takes or imperfection (Frost & Steketee, 1997). The perfectionism may relate
to external stimuli, such as a need to fill out a form without making a single
mistake; or to internal stimuli, such as a need to repeat a routine action until
it feels “just right” (Coles, Frost, Heimberg, & Rheaume, 2003). Such beliefs
are often observed among patients with symmetry and ordering OCD
symptoms; for example, the belief that “I must keep working at something
until it is exactly right” and “Even minor mistakes mean a job is not com-
plete” (OCCWG, 1997).
Intolerance of Uncertainty. Individuals with OCD often hold the er-

roneous belief that it is both important and possible to be absolutely (100%)
certain that negative outcomes will not occur. Even the remote possibility of
highly unlikely events can become a source of great concern. As a result,
harmless intrusive doubts evoke great distress and urges to make sure that,
for example, one did not commit a sin, leave the oven on, make a terrible
mistake, cause something terrible to happen, or get close enough to blood
to contract HIV. If senseless intrusive thoughts about violence and aggres-
sion, sex, or mistakes are appraised as highly significant, these stimuli acti-
vate intolerance for uncertainty, leading patients to worry whether they
yelled curses out loud, put the cat in the freezer, violently raped a coworker,
cheated on their spouse, changed their sexual preference, or committed a
terrible crime. Intolerance for uncertainty in OCD is also characterized by
specificity. At once, a patient who is unable to accept uncertainty associated
with his or her idiosyncratic obsessional fear might be perfectly able to live
with uncertainties associated with everyday activities; for example, the
possibility of having a car accident on the way to the therapy session. Thus,
intolerance for uncertainty plays a central role in obsessions and underlies
the pathological decision making and need for reassurance that patients of-
ten display (Foa et al., 2003; Tolin, Abramowitz, Brigidi, & Foa, 2003).
Data from three lines of evidence—self-report questionnaire research,

laboratory experiments, and naturalistic longitudinal studies—support
the notion that misinterpretations of intrusive thoughts underlie OCD
symptoms. Numerous questionnaire studies consistently indicate that peo-
ple with OCD are more likely than those without OCD to interpret intrusive
thoughts as significant, threatening, or in terms of responsibility for harm
(e.g., Abramowitz, Whiteside, Lynam, & Kalsy, 2003; Freeston et al., 1993;
OCCWG, 2003; Salkovskis, et al., 2000; Shafran et al., 1996). For example,
my colleagues and I found higher likelihood TAF scores among OCD pa-
tients as compared to anxious and nonanxious control groups
(Abramowitz, Whiteside, Lynam, & Kalsy, 2003). Although studies like this
one show relationships between cognitive biases and OCD symptoms, they
WHAT CAUSES OCD? 71
are merely correlational and therefore do not address whether cognitive bi-
ases play a causal role in OCD (it cannot be ruled out that cognitive biases
result from the presence of OCD symptoms).
Several laboratory experiments have prospectively addressed the effects
of interpretations of intrusive thoughts on OCD symptoms (Ladouceur et
al., 1995; Lopatka & Rachman, 1995; Rachman et al., 1996; Rassin,
Merckelbach, Muris, & Spaan, 1999). Perhaps the most clever of these was
the study by Rassin et al. (1999) that addressed the role of TAF in the etiol-
ogy of OCD. The researchers connected 45 psychologically naive partici-
pants to electrical equipment that, participants were told, would monitor
their thoughts for 15 minutes. To induce TAF, participants who had been
randomly assigned to the experimental condition were told that thinking
the word apple would automatically result in a mild electric shock to an-
other person (a confederate of the experimenter) they had met earlier. Par-
ticipants were also informed that by pressing a certain button immediately
after having an apple thought, they could prevent the shock—this was in-
tended to be akin to a neutralizing response. On the other hand, partici-
pants in the control group were told only that the electrical equipment
would monitor their thoughts. Results indicated that during the 15-minute
monitoring period, the experimental group reported more intrusive apple
thoughts, more guilt, greater subjective discomfort, and more intense resis-
tance to thoughts about apples compared to the control group. Moreover,
there was a strong association between the number of reported apple
thoughts and the number of button presses. Thus, experimentally induced
TAF (i.e., the belief that one’s thoughts can produce harmful and
preventable consequences) evoked intrusive distressing thoughts and
neutralizing behavior profoundly similar to clinical OCD symptoms.
The causal effects demonstrated under highly controlled laboratory
conditions might or might not extend to the development of OCD in natu-
ralistic settings. Thus, longitudinal studies in which individuals who are
likely to experience an increase in responsibility are assessed for vulnera-
bility and then followed up after some critical event are apt to be particu-
larly informative. In one such prospective study, my colleagues and I
administered the Obsessive Beliefs Questionnaire (OBQ; OCCWG, 2003)
to 75 expecting parents before the birth of their first child (Time 1). The
OBQ assesses the domains of dysfunctional beliefs summarized in Table
3.2. Between 2 and 3 months after childbirth (Time 2), we assessed the
presence and intensity of parents’ unwanted intrusive thoughts about
their newborn. Sixty-six of the 75 new parents (88%) reported unwanted
infant-related thoughts at Time 2 (e.g., an image of dropping the child
down the stairs or off the balcony). As shown in Fig. 3.2, after controlling
for trait anxiety, individuals who scored in the highest quartile on the
OBQ at Time 1 had significantly more intense OCD symptoms (as rated by
72 CHAPTER 3
FIG. 3.2. Mean Yale– Brown Obsessive Compulsive Scale (Y–BOCS) score
by Obsessional Beliefs Questionnaire (OBQ) quartile controlling for scores on
the State–Trait Anxiety Inventory (STAI–Trait version), F(3, 65) = 4.95, p <.005.
Post hoc analysis indicated that the highest OBQ quartile group scored signif-
icantly higher than the other three groups (p < .05).
the Y–BOCS) at Time 2 compared to those scoring in the other three

quartiles. This suggests that the tendency to interpret the presence or
meaning of intrusive thoughts as significant or threatening is a risk factor
for the development of more severe OCD symptoms.
Foundations of Misinterpretations
What predisposes people to magnify the significance of their intrusive

thoughts? Anumber of studies have examined the possible contributions of
parental rearing practices to the development of OCD, yet these have
yielded largely conflicting results. For example, some researchers have
found high levels of parental overprotection in OCD patients (Hafner, 1988;
Merkel, Pollard, Wiener, & Staebler, 1993; Turgeon, O’Connor, Marchand,
& Freeston, 2002), whereas others have reported more rejection and less
caring as compared to nonpatients (e.g., Hoekstra, Visser, & Emmelkamp,
1989), or no significant differences between individuals with and without
OCD (Alonso et al., 2004; Vogel, Stiles, & Nordahl, 1997). Thus, there is not
convincing evidence that certain styles of parental rearing cause OCD.
WHAT CAUSES OCD? 73
Other authors (Rachman, 1997; Salkovskis, Shafran, Rachman, &

Freeston, 1999) have proposed that strict religious orthodoxy might give
rise to overvaluation of thoughts if certain standards for behaving and
thinking are repeatedly admonished by authority figures (e.g., learning
from clergy that it is a sin to think aggressive, blasphemous, or adulter-
ous thoughts). The influence of cultural and religious background on
OCD symptoms has been examined in several studies with largely con-
sistent results lending support for this hypothesis. For example, my col-
leagues and I found that the fear of God and fear of committing sin were
associated with more severe OCD symptoms (particularly doubting and
checking) in a nonclinical sample (Abramowitz, Huppert, Cohen, Tolin,
& Cahill, 2002). In a subsequent study, highly religious Protestants re-
ported more obsessionality, contamination concerns, intolerance of un-
certainty, beliefs about the importance of thoughts, beliefs about the
need to control thoughts, and inflated responsibility, compared to athe-
ists and less religious Protestants (Abramowitz, Deacon, Woods, &
Tolin, 2004). A similar investigation of Catholics revealed almost identi-
cal results (Sica, Novara, & Sanavio, 2002).
Cultural influences are also apparent in the heightened frequency of
contamination obsessions in India, for example, where purity and cleanli-
ness are emphasized as part of Hindu religious doctrines (Akhtar et al.,
1975; Khanna & Channabasavanna, 1988). Similarly, studies of OCD in
Egypt and Turkey find obsessions related to Muslim culture, including con-
tamination and moral or ethical obsessions. Further evidence for the role of
cultural influences can be found in how the content of obsessional concerns
has undergone shifts over time that correspond with changes in societal
concerns. For example, the heightened awareness of anthrax poisoning fol-
lowing the 2001 terrorist attacks in the eastern United States gave rise to
increased obsessions about this particular contaminant.
Salkovskis et al. (1999) proposed several paths to the evolution of in-
flated responsibility beliefs, including learning experiences. For example, a
childhood in which one’s parents convey the message that certain situa-
tions or objects are very dangerous, or that the child is incapable of dealing
with the resulting harm, could lead to obsessions regarding the specific
harbinger of perceived danger. This idea is consistent with previous re-
search finding that patients with severe contamination obsessions came
from families in which cleanliness and perfectionism were emphasized
(Hoover & Insel, 1984). Shafran et al. (1996) proposed that certain experi-
ences, such as a chance pairing between a thought and a negative event,
could lead to a heightened threat value for intrusive mental processes. Al-
though research has not yet addressed this possibility, the following clinical
example demonstrates how coincidental incidents in which it seems that
74 CHAPTER 3
one’s thoughts or actions contribute to a disastrous consequence can make

one vulnerable to developing obsessions.
Brett, an 18-year-old college student and devout Christian, had suffered
with manageable OCD symptoms involving unrealistic fears of making
mistakes since he was a child. On the morning of Saturday, February 1, 2003,
while working on an assignment, his computer crashed and Brett lost all of
his work. At the same time, he heard a television news anchor say that the
space shuttle Columbia was due to land shortly. In his anger over the loss of
his assignment, Brett exclaimed, referring to the space shuttle, “I hope the
damn thing blows up!” Shortly thereafter, news that the Columbia had ex-
ploded on re-entry into Earth’s atmosphere was broadcast. Brett became ex-
tremely anxious and worried that perhaps his thoughts and words had
something to do with the shuttle disaster. He developed intense guilt and
the obsessional fear of causing additional tragedies if he let himself think
any more “bad” thoughts. At his evaluation some months later, Brett stated
that he realized the senselessness of his obsessional fear, but that he recalled
a particular sermon by his pastor about how God knew everyone’s
thoughts, and how thinking about a sin was as morally reprehensible as
committing the sin itself.
Summary
The cognitive-behavioral theory of the development of OCD assumes that

obsessions begin as normal phenomena that come to acquire special nega-
tive significance when they are appraised as threatening. Once perceived in
this way, obsessions evoke distress and become the natural target of
safety-seeking behavior such as avoidance and compulsive rituals, aimed
at reducing distress and the probability of feared consequences. Several
lines of research support this hypothesis and collectively suggest that peo-
ple with OCD are not abnormal in terms of the occurrence of obsessional
thoughts. Rather, they are experiencing anxiety over ordinary distressing
intrusive thoughts in much the same way that people with social phobia
worry about scrutiny from others and those with panic disorder cata-
strophically misinterpret harmless anxiety-related body sensations. The
origins of catastrophic beliefs about intrusive thoughts remain speculative,
with the possible exception of certain forms of religiosity. In the next chap-
ter the factors that serve to maintain OCD symptoms are discussed.
4
The Maintenance
of Obsessions and Compulsions
Within a theoretical framework it is necessary to distinguish between etio-

logical and maintenance processes because maladaptive thinking and be-
havior might begin for one reason, yet persist for other reasons. Knowledge
of causal factors is helpful for the purposes of prevention or relapse preven-
tion following successful treatment. Understanding factors that maintain a
disorder is most useful in psychological treatment because reversing these
factors will weaken existing symptoms. Patients also benefit from under-
standing the psychological processes involved in the maintenance of their
problem, as this understanding provides them with a compelling rationale
for undertaking therapy (as discussed in chapter 5). Moreover, understand-
ing this rationale appears to play a role in the successful treatment of OCD
(Abramowitz, Franklin, Zoellner, & DiBernardo, 2002).
As presented in chapter 3, the cognitive-behavioral model of OCD posits
that clinical obsessions develop when normally occurring intrusive
cognitions are appraised in ways that lead them to acquire negative emo-
tional significance. Avoidance, compulsive rituals, and other forms of neu-
tralization are undertaken as natural safety-seeking responses that
function to reduce obsessional distress. However, if OCD patients’ dys-
functional beliefs and interpretations are mistaken in the first place, why do
these thinking and behavioral patterns persist? That is, if unwanted intru-
75
76 CHAPTER 4
sive thoughts and other feared stimuli such as numbers, doorknobs, floors,
imperfection, uncertainty, and so on are not really as dangerous as patients
anticipate, why do patients not recognize this, correct their flawed think-
ing, and stop performing senseless and redundant rituals? The first part of
this chapter seeks to answer these questions by explaining the factors that
maintain OCD symptoms. Next, particular maintenance processes associ-
ated with each of the OCD symptom dimensions are described. The chapter
closes with a discussion of treatment implications of the cognitive-behav-
ioral conceptualization. The conceptual model I present is largely based on
the pioneering work of Rachman (e.g., Rachman, 1997, 1998) and
Salkovskis (e.g., Salkovskis, 1985, 1989).
MAINTENANCE FACTORS
Selective Attention to Threat Cues
Once an intrusive thought or other stimulus is appraised as threatening it,

takes on negative emotional significance and, like all threat cues, becomes
a mental priority. This phenomenon is a more or less automatic part of the
body’s innate danger detection system—the fight-or-flight response—that
kicks into gear whenever threat is perceived. By causing us to scan our
surroundings and become hypervigilant for danger cues, this mechanism
helps us figure out how to protect ourselves in the event that actual dan-
ger is lurking. Although this is often an involuntary process, some pa-
tients adopt a more deliberate anticipatory strategy of hypervigilance and
scanning if they believe such tactics are necessary to avoid perceived
threat. As a result of this heightened cognitive self-consciousness, the in-
dividual becomes exquisitely sensitive to his or her unwanted thoughts. It
is as if the threshold for a thought to be “unacceptable” has been lowered.
Thus, someone concerned with immoral sexual thoughts begins to notice
more sexual thoughts. Similarly, someone with concerns about symmetry
and orderliness is primed to identify things that are not “just right.” An in-
dividual who fears contamination from urine looks carefully for (and of-
ten finds) yellow stains that could be urine. A person with somatic
obsessions becomes highly sensitive to bodily sensations as would some-
one with panic disorder.
The tendency to selectively attend to obsessional stimuli also helps to ex-
plain the uncontrollable and repetitive nature of obsessions, as well as the
common complaint among people with OCD that their particular feared
situations and intrusive thoughts seem to confront them at every turn. This
experience is typified by one patient with contamination obsessions who
remarked that “God must be toying with me by placing so many piles of
dog shit along my jogging route everyday.” Of course, this person’s
MAINTENANCE OF OBSESSIONS AND COMPULSIONS 77
overconcern with feces has led him to become increasingly hypervigilant of

such stimuli (whereas others do not give such experiences much mental
priority). A related effect is that the tendency to closely monitor and thereby
notice more “danger signs” leads the person to conclude that danger is on
the increase, which reinforces dysfunctional beliefs about the hazards of
obsessional stimuli.
Physiologic Factors
Anxiety associated with obsessional thoughts also elicits autonomic (sym-

pathetic) arousal as part of the body’s physiological reaction to stress (fight
or flight). This instinctive and highly adaptive response serves to protect
the organism from danger by preparing it for immediate action (i.e., attack
or run) if danger becomes imminent. When danger is anticipated, adrena-
line is released into the bloodstream, producing noticeable physiologic ef-
fects including (but not limited to) an increase in heart rate and breathing,
muscle tension, onset of cold or hot flashes, dilation of the pupils, and gas-
trointestinal distress (Barlow, 2002). What is the relevance of the physiol-
ogy of anxiety to the maintenance of OCD? Clinical observations and
research findings suggest that anxiety patients often adopt a type of emo-
tional reasoning in which anxiety-related physiological effects are used to
validate beliefs about danger (Arntz, Rauner, & van den Hout, 1995). For
example, “I feel anxious, therefore there must be something to fear.” This is
called ex-consequentia reasoning because the person concludes not only that
perceiving danger results in feeling anxious, but that feeling anxious im-
plies the presence of danger. For individuals with OCD, inferring danger
on the basis of anxiety evoked by mistaken beliefs about objectively safe sit-
uations and thoughts serves to reaffirm the mistaken beliefs, thereby main-
taining OCD symptoms.
Safety-Seeking Behavior: Rituals and Neutralization
A person experiencing obsessional anxiety (or any other perceived threat)

is motivated to take action to reduce the probability of anticipated negative
outcomes or neutralize the anxiety or discomfort (Salkovskis, 1985). As I
described in chapter 1, strategies such as compulsive rituals, mental com-
pulsions, reassurance seeking, and various other neutralizing responses to
obsessional distress can be jointly conceptualized as safety-seeking behav-
iors because they are performed with the intent of minimizing, or alto-
gether preventing feared consequences of exposure to obsessional cues
(Salkovskis, 1991). Safety seeking is a normal and adaptive response to
threatening circumstances. If the building you are in was on fire, you would
try to escape as quickly as you could. However, in OCD, the obsessive fear
78 CHAPTER 4
is irrational. That is, the risk of harm is objectively low. There is therefore no
actual need for escape from obsessions. From the standpoint of condition-
ing theory, safety behaviors contribute to the persistence of irrational fear
because they prevent the natural extinction of anxiety (and compulsive
urges) that occurs through prolonged encounters with feared stimuli in the
absence of disastrous consequences. By using safety behavior to terminate
exposure to feared stimuli, the individual with OCD never has the opportu-
nity to learn that danger is not actually present.
The cognitive-behavioral model proposes that the choice of a particular
safety strategy (or strategies) is linked to beliefs about feared outcomes as-
sociated with obsessional thoughts, situations, or stimuli. These examples
illustrate the relationship between beliefs and safety-seeking behavior:
• A man who interprets his intrusive thoughts of violence as meaning

that he is a sinful person might compulsively pray or covertly “cancel
out” the thoughts with a mental ritual.
• A woman who overestimates the risk of danger from contact with a
public toilet will engage in ritualistic washing or cleaning after using
the bathroom.
• Someone who believes his or her intrusive doubts about discarding
important information signify that he or she is likely to make such
mistakes might compulsively check to achieve certainty about the ab-
sence of such errors.
• A patient who perceives that he or she did not perform an activity
“just right” might repeat the activity until it is carried out perfectly.
To explain the habitual (repetitive, compulsive) use of safety behaviors,

the cognitive-behavioral model adopts an operant conditioning explanation:
Performance of safety-seeking behaviors is negatively reinforced by the
short-term reduction in obsessional fear it produces. Thus, under similar cir-
cumstances of obsessional fear, the behaviors are increasingly likely to be
performed again. The model also draws attention to two incidental and
counterproductive long-term effects of safety behaviors. First, performance
of safety-seeking behaviors prevents an unambiguous disconfirmation of
faulty beliefs (e.g., misappraisals of obsessional thoughts). That is, when the
feared outcome does not occur, the person is prone to believing that he or she
narrowly escaped disaster by performing the safety behavior. Thus the
safety behavior interferes with learning that the fear was unrealistic to begin
with. Second, the very effort put toward performing safety-seeking behavior
leads to increased preoccupation with the obsessional thoughts or stimuli
that evoked the safety behavior. Thus, the very safety-seeking behaviors that
develop into habitual strategies for reducing fear in the short term actually
serve to maintain this fear in the long run.
Results from a number of empirical studies support the hypothesis that

safety-seeking behaviors have deleterious effects. In one elegant experi-
ment using 29 individuals with OCD, Salkovskis, Thorpe, Wahl, Wroe, and
Forrester (2003) ascertained each patient’s most disturbing obsessional
thought and preferred strategy for neutralizing the particular obsession.
Each patient then made an audiotape recording of a written version of his
or her most disturbing obsessional intrusion. During the first phase of the
experiment, patients listened to the tape while being instructed to either
use their preferred neutralizing strategy (e.g., mental rituals) or simply
count backwards from 20 (a distraction task). During the second phase,
which occurred 15 minutes later, all participants again listened to their ob-
sessional thoughts for 8 minutes, this time without any neutralizing or dis-
traction. Ratings of subjective discomfort were obtained throughout both
phases of the study.
The findings from this study can be summarized as follows: During the
first phase of the experiment (neutralizing or distraction), only the pa-
tients who used their typical neutralizing strategies experienced a de-
crease in subjective discomfort while listening to their obsession.
However, during the second phase, patients who had previously neutral-
ized reported an increase in their discomfort while listening to their ob-
session. Moreover, these patients evidenced stronger urges to neutralize
during the second phase relative to patients in the distraction condition.
Salkovskis et al.’s (2003) findings are consistent with the cognitive-behav-
ioral model and replicate the earlier work of Rachman and his colleagues
(e.g., Roper & Rachman, 1976), demonstrating that safety-seeking behav-
ior, in this case neutralizing, is associated with short-term anxiety reduc-
tion. The results also demonstrate that neutralizing leads to increases in
discomfort and urges to neutralize during subsequent encounters with
obsessional thoughts.
As a clinical illustration let us consider Heidi, a nurse who reported re-
current intrusive doubts that she made mistakes in a patient’s medical chart
that could lead to the patient’s death (e.g., recording the wrong medication
dose). Although quite cautious and deliberate in her work, Heidi experi-
enced persistent urges to recheck her work excessively. She often called her
coworkers from home (e.g., on her days off) to ask that they review her
charts for errors and reassure her that no patients had died. The coworkers
typically complied with Heidi’s requests for assurance, which temporarily
alleviated her obsessional distress.
Despite the short-term success of her reassurance-seeking rituals,
Heidi’s intrusive doubts, obsessional distress, and compulsive behaviors
grew more intense. According to the cognitive-behavioral model, her
symptoms persisted because she (like most OCD patients) attributed the
nonoccurrence of feared catastrophes and reduction of anxiety to the com-
80 CHAPTER 4
pulsive safety-seeking behavior. That is, she erroneously believed the ab-
sence of patient deaths was a direct result of her compulsive behavior:
“Had I not been so careful, patients might have died because of me” (an in-
flated sense of responsibility is evident here). Put another way, Heidi’s ritu-
als prevented her from realizing that even if she did not check, terrible
consequences would be unlikely and her anxiety would eventually dissi-
pate. In addition, performing compulsive behavior increased the frequency
of obsessional thoughts simply by drawing increased undue attention to-
ward the intrusions (e.g., “If I have to call my coworkers so much, these
doubts must be important”). Thus, as shown in Fig. 4.1, safety-seeking
behavior contributes to a vicious cycle that maintains OCD symptoms and
gains habit strength with repetition.
FIG. 4.1. Vicious cycle resulting from the use of safety-seeking behaviors to
reduce obsessional distress.
Passive Avoidance
As discussed earlier, behavioral retreat from obsessional fear cues also

contributes to the maintenance of OCD. In the short term, avoidance
clearly results in a decrease or termination in exposure to threat. This re-
duction in fear negatively reinforces future avoidant responses; therefore
avoidance sustains itself over time. However, consistent avoidance also
prevents the person from having corrective experiences that might other-
wise modify dysfunctional beliefs and interpretations of intrusive
thoughts and other fear-related stimuli. Moreover, patients tend to misin-
terpret the effects of their habitual avoidance. For example, a man who
uses only self-flush urinals in public restrooms (thereby avoiding having
to touch the flushing device) continues to believe that flushing the toilet is
dangerous and that he has remained healthy only because he uses
self-flush toilets. Thus, the dysfunctional appraisals and overestimates of
threat that fuel obsessional fear remain intact.
Concealment of Obsessions
Concealing from others the content and regularity of obsessional thoughts

is a form of avoidance that deserves elaboration because it is frequently
overlooked by clinicians. If a person attaches negative personal meaning
and significance to their unwanted intrusive thoughts, images, impulses,
or ideas, it is understandable that they will want to keep these “dirty little
secrets” hidden from other people (Newth & Rachman, 2001). Typically, it
is unacceptable religious, sexual, and aggressive or violent obsessions (as
opposed to contamination concerns or fears of mistakes) that are concealed.
Patients with these types of obsessions worry about others’ negative reac-
tions to the content and frequency such thoughts. For example:
• The pastor would think I was a fake if he found out that I have so
many intrusive doubts about God’s existence.
• What would my family think if they knew I had thoughts about sleep-
ing with Heather (the patient’s first cousin)?
• My doctor would have me committed if I told him I was having intru-
sive ideas of suffocating the baby.
The habitual concealment results in the preservation of the patient’s per-

ception that his or her intrusions indicate some deep, dark, unspeakable
personality defect. Patients continue to believe that they are the only ones
experiencing such thoughts. More specifically, it reduces the likelihood of
their learning (perhaps through socialization) that others (a) most likely do
not become horrified on learning of the thoughts, (b) presumably can relate
82 CHAPTER 4
to these experiences themselves, and (c) probably hold alternative (health-

ier) explanations of the meaning and significance of the intrusions.
Paradoxical Effects of Thought Control
Active resistance to intrusive obsessional thoughts takes many forms. In

addition to compulsive rituals and other safety-seeking behaviors, patients
with OCD often engage in an ongoing struggle for mental control in which
they attempt to dismiss or regulate their unwanted distressing thoughts.
These efforts are no doubt motivated by dysfunctional beliefs regarding the
importance of controlling one’s own thoughts; for example “Losing control
of my thoughts is as bad as losing control of my behavior,” and “Control
over thoughts is an important part of self-control” (e.g., Purdon & Clark,
1993). As I describe later, efforts to suppress or gain control over cognitive
intrusions are generally counterproductive, resulting in a paradoxical in-
crease in the unwanted thought and maintenance of OCD symptoms.
Consider the example of Joseph, an Orthodox Jew who described obses-
sional thoughts of curse words that came to mind each time he entered a
synagogue, read the Torah, or tried to pray. Joseph was terrified that these
intrusions meant that he was a fraud who harbored a deep-seated hatred of
God, Judaism, and the Torah. He felt extremely guilty and fearful that oth-
ers would find out about the thoughts and label him a “bad Jew.” He won-
dered what God thought of him for having such blasphemous thoughts. In
addition to a number of compulsive rituals aimed at neutralizing the feared
effects of such thoughts, Joseph tried desperately to suppress the intrusions
when they came to mind; yet he had little success doing so. Eventually giv-
ing up his struggle, he started avoiding the synagogue and became in-
tensely depressed. At the urging of his wife, he came to our clinic for
consultation and treatment.
Interest in the relationship between thought suppression and OCD was
generated by the work of Wegner and his colleagues (e.g., Wegner, Schnei-
der, Carter, & White, 1987), who asked their research participants (under-
graduate students) to spend 5 minutes trying not to think of a white bear.
Results indicated that attempts to suppress such thoughts were often futile
and even led to an increase in the frequency of white bear thoughts after
suppression instructions were relaxed—a phenomenon termed the rebound
effect. To determine whether this paradoxical phenomenon extended to in-
dividuals with OCD, we (Tolin, Abramowitz, Przeworski, & Foa, 2002) de-
signed a study similar to that of Wegner et al. (1987) and found that patients
indeed reported difficulty suppressing white bear thoughts. A large body
of research on thought suppression in clinical and nonclinical samples has
accumulated since Wegner’s initial work. Our own comprehensive meta-
analytic review of this research (Abramowitz, Tolin, & Street, 2001) re-
vealed support for the hypothesis that deliberately trying to suppress a

thought leads to an increase in that particular thought (although not all
studies have found consistent results; e.g., Purdon, Rowa, & Antony, 2005).
Thus, attempting to suppress intrusive thoughts probably plays an impor-
tant role in obsessional problems (e.g., Rachman, 1997; Salkovskis, For-
rester, & Richards, 1998; Wegner, 1994). Just when patients are trying to
expel unwanted thoughts from consciousness, they are priming them-
selves to experience an increase in the unwanted thoughts. The “solution”
has become part of the problem.
Thought Suppression Failure. It also appears that maladaptive inter-

pretations of thought suppression failure, apart from negative appraisals of
intrusive thoughts in general, contribute to the maintenance of OCD
(Janeck, Calamari, Riemann, & Heffelfinger, 2003; Purdon et al., 2005). Ex-
amples of such appraisals include, “Since I can’t stop these thoughts even
when I try very hard, deep down I must really want something bad to hap-
pen,” and “I must really be a terrible person if I keep thinking this way de-
spite trying to stop.” Consistent with this idea, we (Tolin, Abramowitz,
Hamlin, Foa, & Synodi, 2002) found that people with OCD interpreted their
thought suppression failures as a sign of personal weakness (i.e., “I am
mentally weak”) rather than attributing them to realistic situational factors
(i.e., “It is often difficult to suppress unwanted thoughts”). Beliefs that one
is personally weak, in turn, lead to a decline in mood (Purdon, 2001) and the
perceived need to intensify suppression efforts. The result, as in Joseph’s
case presented earlier, is a sense that catastrophic beliefs about the conse-
quences of failing to control thoughts are coming true, leading to a self-per-
petuating cycle of suppression, intrusion, and self-defeating beliefs.
Therefore, it is important to accurately identify and target patients’ ap-
praisals of thought recurrences (Purdon et al., 2005).
Thought Control Strategies. Patients with OCD seem to use addi-

tional maladaptive strategies when attempting to regulate intrusive
thoughts. The Thought Control Questionnaire (TCQ; Wells & Davies,
1994) measures the tendency to use five different strategies: (a) distraction
(e.g., “I keep myself busy”), (b) social control (e.g., “I talk to a friend about
the thought”), (c) worry (e.g., “I think about past worries instead”), (d)
punishment (e.g., “I tell myself something bad will happen if I think the
thought”), and (e) reappraisal (e.g., “I challenge the thought’s validity”).
In one study, we gave this measure to groups of OCD patients, panic pa-
tients, and healthy controls, finding that compared to the other groups, in-
dividuals with OCD reported more frequent use of worry and
punishment strategies, and less frequent use of distraction (Abramowitz,
Whiteside, Kalsy, & Tolin, 2003). Because punishment and worry (in con-
84 CHAPTER 4
trast to social, distraction, and reappraisal strategies) likely evoke nega-

tive affect and selective attention to the intrusive thought, these data
suggest that such strategies serve to maintain mistaken beliefs and dis-
tress associated with intrusive thoughts.
Summary of Maintenance Factors

A summary of the maintenance factors just described appears in Table 4.1.
From the cognitive-behavioral perspective, OCD is largely a problem in
which otherwise harmless unwanted intrusive thoughts have become a
focus of concern. Threat-related appraisals and interpretations of such
thoughts (and other related stimuli) evoke an array of responses that in-
advertently increase the frequency of cognitive intrusions and reinforce
maladaptive beliefs about their potential for harm. This leads to a self-sus-
taining vicious cycle of intrusions, maladaptive beliefs, anxiety, ill-fated
responses, intrusions, and so on that becomes more and more insidious
with repetition. Observations that some individuals with OCD spend
their entire day engaged in ritualistic behavior or devise elaborate avoid-
ance strategies that so restrict their ability to function are a testament to
the insidiousness of the vicious cycle. In a very real sense, the means by
which individuals with OCD appraise and attempt to manage their intru-
sive thoughts eventually become more perilous than the intrusions them-
selves. A graphical depiction of the cognitive-behavioral model is
presented in Fig. 4.2.
The cognitive-behavioral approach provides a clearly articulated, logi-
cally sound, and empirically verifiable account for the symptoms of OCD
that is derived from normal human learning principles (i.e., conditioning)
and normal cognitive processes. There is no appeal to chemical imbal-
ances, disease states, or general deficits to explain the origin or mainte-
nance of obsessions and compulsions. Even the kinds of biased thinking
implicated in the transformation of normal intrusions into obsessions are
not in themselves “disturbed” because everyone makes incorrect judg-
ments about situations and stimuli from time to time. And when faced
with a perceived threat it is highly adaptive to take action to avoid or re-
duce the anticipated danger. So, the safety-seeking behavior observed in
OCD is neither mysterious nor uniquely pathological. It is, however,
self-preserving in that it prevents the person from correcting their faulty
beliefs and judgments.
THE COGNITIVE-BEHAVIORAL MODEL

AND SYMPTOM DIMENSIONS
The cognitive-behavioral conceptual framework is fairly broad and

therefore generalizes well to most individuals with OCD. However, al-
TABLE 4.1
Summary of Factors Involved in the Maintenance of OCD
Maintenance Factor Description

Selective attention Hypervigilance for threat cues is an adaptive response, yet it leads to noticing more threatening
stimuli, including unwanted thoughts.
Physiological factors The fight-or-flight response is an innate response to perceived threat. OCD patients often use emo-
tional reasoning to infer that situations are dangerous on the basis of feeling anxious. This reaffirms
mistaken beliefs that lead to feeling anxious.
Safety-seeking behavior Efforts to reduce obsessional anxiety or prevent feared consequences of obsessions include overt
compulsive rituals, mental rituals, and various overt and covert neutralizing strategies. These be-
haviors reduce distress in the short term and are thereby reinforced. In the long term, habitual use of
safety behaviors prevents disconfirmation of mistaken beliefs because of how their outcomes are in-
correctly interpreted (e.g., “If I didn’t wash my hands I would have become very sick,” “If I didn’t
say the prayer perfectly, my relatives would have died”).
Passive avoidance Leads to short-term anxiety reduction, but prevents extinction of anxiety and disconfirmation of
overestimates of risk because the individual never has the opportunity to find out that danger is un-
likely.
Concealment of obsessions Prevents disconfirmation of mistaken beliefs about intrusive thoughts because the individual is
never exposed to corrective information through social outlets.
Attempted thought control Attempts to control or suppress unwanted thoughts paradoxically lead to an increase in the un-
wanted thoughts. Misappraisal of thought control failure leads to further distress.
85
86 CHAPTER 4
FIG. 4.2. Cognitive-behavioral conceptual model of the maintenance of OCD.
though many of these cognitive and behavioral characteristics are pres-

ent to some extent across the range of OCD symptom themes, different
manifestations of the disorder may be typified by some features more
than others. To help the clinician develop a specific conceptualization of
patients presenting with different symptom themes, we briefly consider
the cognitive characteristics and maintenance factors of the OCD symp-
tom dimensions described in chapter 1: harming, contamination, incom-
pleteness, and unacceptable thoughts. These characteristics are also
summarized in Table 4.2.
Harming
Clinical and research observations indicate harm-related obsessions are

associated with overestimation of the probability and “awfulness” of
TABLE 4.2
Prominent Cognitive and Behavioral Characteristics of Different OCD Symptom Dimensions
Prominent Appraisals
Dimension Intrusive Thoughts of Intrusive Thoughts Prominent Maintenance Factors
Harming • Thoughts of mistakes, accidents Overestimates of likelihood and cost Checking for safety, seeking
• Thoughts or images of fires, of danger, exaggerated responsibility reassurance (asking questions),
burglaries, serious diseases for preventing harm, intolerance for mental and behavior
uncertainty, likelihood TAF neutralizing, avoidance
Contamination • I or others will become ill Overestimates of the likelihood and Passive avoidance, compulsive
• Disgust costs of danger, responsibility for washing
• Thoughts or images of germs causing or preventing feared
outcomes
Incompleteness • Sense that something is not Imperfection and mistakes are Compulsive ordering and
just right intolerable arranging, repeating routine
• Feeling, thought, or sense activities to achieve a sense of
of asymmetry perfection or completeness
Unacceptable • Unwanted violent, sexual, Overimportance of thoughts, Mental rituals, overt and covert
thoughts and or blasphemous thoughts, overestimation of threat, exaggerated neutralization strategies,
covert rituals ideas, images, impulses, sense of responsibility for preventing concealment, avoidance (when
and doubts harm, need to control thoughts possible), thought control and
suppression attempts
87
88 CHAPTER 4
harm, an exaggerated sense of responsibility for preventing harm to one-

self or others, and intolerance for uncertainty about the chances of mis-
fortune (e.g., Rachman, 2002). TAF beliefs may also be present. The chief
maintaining factors for harm-related obsessions include compulsive
checking (e.g., for safety) and reassurance seeking (asking questions).
Subtle rituals and other safety behaviors such as mental compulsions
(prayer, reviewing) and repeating actions (retracing steps) may also be
performed to magically prevent “bad luck” or to cancel out or neutralize
the perceived danger. Although compulsive checking and other safety
behaviors are intended to achieve a sense of certainty and reduce anxi-
ety, they inadvertently cultivate obsessional fear as described in previ-
ous sections.
Contamination
The most prominent cognitive features of contamination obsessions are

overestimates of the likelihood and costs of illnesses associated with the
feared contaminant (e.g., Jones & Menzies, 1997a). One patient feared
she would easily get herpes (cold sores) from touching surfaces such as
elevator buttons and door handles, and by using other people’s pens or
telephones (overestimate of likelihood). She also worried that if she had
cold sores, she would be ostracized by her coworkers for being unclean
and forsaken by her family for the rest of her life (overestimate of cost).
Some patients do not articulate such specific feared consequences, but
instead say they feel as if anxiety will persist indefinitely if exposed to
sources of contamination (a form of perfectionism). Overestimates of
danger and use of avoidance bring to light parallels between contamina-
tion fears in OCD and specific phobias.
The distinguishing factor between contamination obsessions and
phobias is the presence of responsibility cognitions in OCD. That is, pa-
tients with contamination obsessions tend to believe that they can (and
therefore must) act to prevent negative consequences by engaging in
washing or cleaning rituals (Menzies, Harris, Cumming, & Einstein,
2000). The presence of responsibility cognitions is perhaps best illus-
trated by contamination obsessions involving the fear that one will be
accountable for infecting others with contaminants. For example, one
woman was obsessed with concerns that her dishwasher might not do an
adequate job of disinfecting the family dishes and silverware, and as a
result, her family (particularly her young children) might become sick.
To “prevent” sickness, she therefore scrubbed each item after it had been
through the dishwasher and again before using it to serve food to her
family. Interestingly, when preparing food only for herself, this patient
was not nearly as concerned about becoming sick. In this example, the
patient believed she held the pivotal power to prevent disastrous conse-
quences from befalling others.
Incompleteness
Intrusive thoughts regarding symmetry, exactness, and the sense that

something is not just right are relatively common experiences, yet may de-
velop into obsessions if appraised as intolerable (Coles, Frost, Heimberg, &
Rheaume, 2003). Thus, perfectionistic beliefs about mistakes, orderliness,
and symmetry appear to dominate within this symptom dimension. Pa-
tients may not be able to articulate fears of specific negative catastrophes,
and instead experience general distress associated with the imperfection
they are confronted with (e.g., “the shoes don’t feel even,” “the clothes
aren’t arranged properly,” “I didn’t close the door just right”). Compulsive
rituals such as ordering, arranging, and repeating actions serve the obvious
purpose of reducing distress. However, from a learning standpoint, they
maintain perfectionistic beliefs because they prevent the natural extinction
of incompleteness-related distress. From a cognitive-behavioral perspec-
tive, rituals reinforce beliefs that imperfection, asymmetry, and disorderli-
ness are distressing and intolerable, and that the only way to reduce this
distress is by removing the not just right feeling. Thus, patients fail to learn
that they would eventually stop worrying about the imperfection even if no
rituals were performed.
Overly negative appraisals of the occurrence and content of intrusive vio-

lent or aggressive, sexual, and religious (blasphemous) thoughts, ideas, im-
ages, doubts, and urges characterize the unacceptable thoughts symptom
dimension. Patients interpret their obsessional thoughts as morally unac-
ceptable, indicative of some serious personal flaw, and in terms of personal
responsibility for reducing or preventing harm to oneself or others (e.g.,
acting on the thought). As a result, sufferers often believe that they can and
should control or suppress such repugnant, senseless thoughts. Common
safety-seeking behaviors include mental compulsions and other neutraliz-
ing strategies, as well as concealment, avoidance (when possible), and vari-
ous forms of thought control or suppression to minimize distress or the
perceived probability of danger. The short-term success of safety behaviors
in reducing anxiety reinforces distorted interpretations of the intrusive ob-
sessional thoughts and prevents extinction of associated anxiety. As dis-
90 CHAPTER 4
cussed previously, the general failure of thought control strategies often

leads to secondary distress and an increase in the very intrusive thoughts
that the person is trying to dismiss.
TREATMENT IMPLICATIONS
OF THE COGNITIVE-BEHAVIORAL MODEL
It follows from the cognitive-behavioral model that effective treatment of

OCD must help patients (a) modify their erroneous interpretations of intru-
sive thoughts and other obsessional stimuli, and (b) eliminate avoidance,
safety-seeking behavior, and other responses that serve as barriers to the
natural extinction of obsessional fear and the self-correction of the errone-
ous interpretations. Patients must understand their problem not in terms of
the risk of feared consequences, but in terms of how they are thinking and
behaving in response to stimuli (e.g., intrusive thoughts) that objectively
pose a low risk of harm. Individuals with washing compulsions must see
their problem not as the need to prevent illness, but as the need to change
how they respond to intrusive thoughts of germs, illness, or contamination
as cued by situations that actually pose little risk of danger. Similarly, those
with checking rituals are helped to view their problem not as how they are
going to reassure themselves that dreaded mistakes will not occur, but as
one in which they are lending too much significance to intrusive ideas,
thoughts, doubts, and images about possible harm.
This conceptualization implies the need for a thorough assessment of the
patient’s obsessional cues (intrusive thoughts and external stimuli) and ap-
praisals of these stimuli. In addition, particulars about the use of safety be-
haviors and other tactics for responding to obsessional stimuli must be
precisely understood. Assessment culminates in the collaborative (i.e., the
patient and therapist) development of an individualized account of the
cognitive and behavioral mechanisms underlying the patient’s OCD symp-
toms, and a plan for reversing these mechanisms using empirically vali-
dated treatment procedures.
Four such procedures are used in the cognitive-behavioral treatment of
OCD. First, patients are educated about the normalcy of intrusive mental
stimuli, the ways in which misinterpreting such stimuli leads to obsessions,
and the ways in which obsessional fear is maintained. Second, cognitive
therapy procedures similar to those used in the treatment of depression
(Beck & Emery, 1985) are implemented to help patients identify and chal-
lenge distorted beliefs about intrusive thoughts and other obsessional stim-
uli. Exposure and response prevention, the third and fourth procedures, are
incorporated as in traditional behavior therapy, with an emphasis on using

these techniques to modify dysfunctional cognitions and weaken connec-
tions between obsessional stimuli and anxiety, and between safety behav-
iors and anxiety reduction. The next chapter provides an overview of these
treatment procedures and reviews the strong evidence for their effective-
ness. The second part of this book details the implementation of these
evidence-based assessment and treatment techniques.
5
Overview of Cognitive-
Behavioral Therapy for OCD
Cognitive-behavioral therapy (CBT) is a time-limited, structured, and ac-

tive psychological treatment that is based on an empirically consistent rela-
tionship among symptoms, the treatment procedures, and a specified
outcome. In contrast to some forms of psychotherapy where the emphasis
is on elucidating the origins of the disorder, CBT targets the processes that
maintain undesirable emotional and behavioral symptoms. In the case of
OCD, the patient’s symptoms are conceptualized as maladaptive patterns
of thinking (i.e., misinterpreting the importance of obsessional stimuli in
ways that evoke anxiety) and behaving (i.e., responding to obsessional dis-
tress using safety-seeking strategies). CBT helps to weaken these patterns
by teaching patients to implement a repertoire of new (more effective)
skills. Therapy represents a collaborative effort between the therapist and
patient, yet in many ways it resembles education, coaching, or tutoring.
The therapist, armed with understanding and expertise, takes the role of in-
structor; and the patient, the role of student. Whereas a positive therapeutic
relationship is important for successful outcome in CBT, it alone is not con-
sidered to be the agent of change. Instead, the aim of the therapeutic rela-
tionship is to foster the development of the patient’s new competencies.
When a person presents for psychological treatment, he or she assumes
that the treatment provider possesses expertise that is superior to that
92
COGNITIVE-BEHAVIORAL THERAPY FOR OCD 93
available through consultation with friends, family members, clergy, or

the local bartender. Clinicians therefore have a professional and ethical
obligation to provide treatments that are likely to be beneficial, and not to
provide treatments that are not likely to be helpful. For this reason it is im-
portant for practitioners to stay informed of the scientific evidence re-
garding the treatment techniques they use. Alas, an important strength of
CBT for anxiety disorders is that it has stood the test of scientific scru-
tiny—it is evidence based. That is, the procedures applied in the treatment
of anxiety problems such as OCD have been consistently demonstrated to
be beneficial in controlled studies comparing them with other credible
treatments of known value.
The major CBT techniques with proven effectiveness for reducing OCD
symptoms are exposure, response prevention, and cognitive therapy (CT).
This chapter provides a concise description of these procedures and re-
views research substantiating their effectiveness. Findings from research
on factors related to successful treatment response and the effects of CBT in
comparison to (and in combination with) medications for OCD are also pre-
sented. Detailed guidelines for planning and implementing CBT tech-
niques are provided in Part II of this volume.
EXPOSURE AND RESPONSE PREVENTION
Exposure and response prevention (ERP) are behavior therapy techniques

that entail confrontation with stimuli that provoke obsessional fear, but that
objectively pose a low risk of harm. Exposure can occur in the form of re-
peated actual encounters with the feared situations (situational or in vivo
exposure), and in the form of imaginal confrontation with the feared conse-
quences of confronting these situations (imaginal exposure). For example,
an individual with obsessional fears of bad luck from the number 13 would
be asked to practice writing the number 13 for situational exposure. She
would also practice imaginal exposure to thoughts and images of being
held responsible for causing bad luck. A patient with fears of becoming
contaminated might be asked to touch objects of increasing “dirtiness”—a
doorknob, the floor, a toilet—for situational exposure. He would then con-
front images of germs for imaginal exposure.
As would be expected, when an exposure task is begun, the patient’s
subjective sense of anxiety is evoked. In fact, patients are encouraged to en-
gage in the exposure task fully and allow themselves to experience this ob-
sessional distress. Over time, the distress (and the associated physiological
responding) naturally subsides—a process known as habituation. With re-
peated exposure, habituation occurs more rapidly. The response preven-
tion component of ERP entails refraining from compulsive rituals and other
safety-seeking behaviors that serve as an escape from obsessive fear. Re-
94 CHAPTER 5
sponse prevention helps to prolong exposure and facilitate extinction of ob-

sessional anxiety. In the preceding examples, the first patient might practice
refraining from any strategies she typically uses to “undo” the effects of ex-
posure to the number 13. She would also refrain from checking for reassur-
ance that bad luck did not occur. The second patient would be instructed to
refrain from decontamination rituals such as washing or cleaning.
The Delivery of ERP
The way ERP is delivered can vary widely, although two meta-analytic
studies suggest that greater effectiveness is achieved when thera-
pist-guided exposure sessions are held multiple times per week, as op-
posed to once weekly (Abramowitz, 1996, 1997). This is probably
because changing the habits that maintain OCD requires a sustained ef-
fort that could be compromised by intersession intervals of longer than a
few days. Research also indicates that substantial beneficial effects,
which are also durable, can occur following a limited number of treat-
ment sessions. It is therefore recommended that an initial course of ther-
apy be limited to about 15 to 20 sessions. One format that has been found
to produce particularly potent effects includes a few hours of assess-
ment and treatment planning followed by 15 daily treatment sessions,
lasting about 90 minutes each, spaced over about 3 weeks (e.g., Franklin,
Abramowitz, Kozak, Levitt, & Foa, 2000). When pragmatic concerns ren-
der this regimen impractical, conducting the treatment sessions on a
twice-weekly basis over 8 weeks works very well for many individuals
with OCD (Abramowitz, Foa, & Franklin, 2003).
At our specialty clinic, patients who live within commuting distance
typically receive the twice-weekly therapy program, whereas those who
travel from out of town are offered the 3-week, daily sessions (intensive
outpatient) option. Regardless of the therapy schedule, treatment sessions
are spent doing exposure tasks with the therapist supervising these exer-
cises. Self-supervised exposure homework practice is also assigned for
completion between sessions. Depending on the patient’s symptom pre-
sentation and the practicality of confronting actual feared situations, treat-
ment sessions might involve varying amounts of situational and imaginal
exposure practice.
A course of ERP ordinarily begins with the assessment of obsessions,
safety-seeking strategies, avoidance behaviors, and anticipated conse-
quences of confronting feared situations. Before treatment commences,
however, the therapist provides a rationale regarding how ERP is helpful
in reducing OCD. This psychoeducational component is an important
step in therapy because it helps to motivate the patient to tolerate the dis-
tress that typically accompanies exposure practice. The treatment ratio-
nale communicates to the patient an explanation of OCD symptoms in

terms that he or she will readily understand. It also prepares the patient
for ERP by letting him or her know that treatment is likely to evoke anxi-
ety, but that this distress is temporary and subsides with time. Informa-
tion gathered during the assessment sessions is then used to plan the
specific exposure exercises that will be pursued. Importantly, the term re-
sponse prevention does not imply that the therapist actively prevents the
patient from performing rituals or other safety-seeking behaviors. In-
stead, the therapist must convince patients to resist their own urges to
carry out these behaviors. Self-monitoring—the keeping of a record of
any response prevention violations—is also implemented.
The exposure exercises in ERP typically begin with moderately distress-
ing situations, stimuli, and images, and progress to the most distressing sit-
uations—which must be confronted during treatment. Beginning with less
anxiety-evoking exposure tasks increases the likelihood that the patient
will learn to manage his or her distress and complete early exposures suc-
cessfully. Mastery of initial exposures increases confidence in the treatment
and helps motivate the patient to persevere during later, more difficult, ex-
ercises. At the end of each treatment session, the therapist instructs the pa-
tient to continue exposure for several hours and in different environmental
contexts, without the therapist. Exposure to the most anxiety-evoking situ-
ations is not left to the end of the treatment, but rather, is completed during
the middle third of the treatment program. This strategy allows the patient
ample opportunity to repeat exposure to the most difficult situations in dif-
ferent contexts to allow generalization of treatment effects. During later
sessions, the therapist emphasizes the importance of the patient’s
continuing to apply the ERP procedures learned during treatment.
The Development of Behavioral Treatments
Before the mid-1960s OCD was considered rare and highly resistant to
treatment. The most common forms of psychotherapy used at that time
were based on psychoanalytic and psychodynamic approaches that em-
phasized the role of unconscious motivation. However, these treatments
were not particularly reliable in reducing obsessions and compulsions as
evidenced by the reputation OCD had as an intractable problem. Early
case histories reporting on the use of select behavioral procedures such as
systematic desensitization, progressive muscle relaxation, flooding,
thought stopping, aversion therapy, and covert sensitization also re-
vealed little evidence of any substantial or durable treatment effects (for a
review see Foa, Steketee, & Ozarow, 1985).
The prognostic picture for OCD began to improve in the mid-1960s and
1970s when Meyer first applied ERP procedures, which had been derived
96 CHAPTER 5
from learning models of OCD as a set of conditioned responses. Meyer’s

(1966) initial open trial study with 15 inpatients found that ERP led to sus-
tained improvement in OCD symptoms. Ten patients responded extremely
well, and the remaining five showed partial improvement. Follow-up stud-
ies conducted several years later revealed that only two of the successfully
treated patients had relapsed (Meyer, Levy, & Schnurer, 1974). These find-
ings generated extensive interest in ERP and led to additional studies
worldwide using more advanced research methodology in both inpatient
and outpatient settings. Studies in England (Hodgson, Rachman, & Marks,
1972; Marks, Hodgson, & Rachman, 1975; Rachman, Hodgson, & Marks,
1971; Rachman, Marks, & Hodgson, 1973), Holland (Emmelkamp &
Kraanen, 1977), Greece (Rabavilas, Boulougouris, & Stefanis, 1976), and the
United States (Foa & Goldstein, 1978) with a total of more than 300 patients
and numerous different therapists affirmed the generalizability of ERP’s
beneficial effects. By the end of the 1980s, ERP was widely considered the
psychological treatment of choice for OCD.
Mechanisms of Change
How does ERP reduce obsessional anxiety and compulsive urges? Foa
and Kozak (1986) proposed that these treatment procedures help patients
modify overestimates of the likelihood of negative outcomes that under-
lie obsessional anxiety. Therefore, it is incumbent on the therapist to engi-
neer exposure tasks that involve fear-evoking experiences in which the
patient expects (unrealistically) that something bad will happen, but
where the feared consequences do not actually occur. Foa and Kozak
(1986) drew attention to three indicators of successful outcome with ERP.
First, physiological arousal and subjective fear must be evoked during ex-
posure. Second, these fear responses must gradually diminish during the
exposure session (within-session habituation). Third, the initial fear re-
sponse at the beginning of each exposure session should decline across
sessions (between-sessions habituation).
Let us consider the example of a patient who washes his hands compul-
sively because he is afraid that he has contracted “bathroom germs” that
will lead to a serious illness. During ERP, this patient would be helped to (a)
repeatedly contaminate himself with bathroom germs by touching objects
that he fears are contaminated, such as the bathroom floor (exposure); (b)
refrain from washing rituals (response prevention); and (c) observe that he
does not become ill. Figure 5.1 depicts the pattern of habituation within and
between four exposure sessions during which this patient confronted bath-
room germs. During each session, the patient sat on the bathroom floor, ab-
stained from all safety behaviors, and practiced eating with his hands. As
illustrated, the initially high levels of discomfort during exposure were
FIG. 5.1. Ratings of subjective distress for an individual with OCD during four
sessions of exposure to“bathroom germs.” The figure illustrates the reduction of
anxiety both within individual sessions as well as across treatment sessions.
temporary, and gave way to the extinction of obsessional anxiety in the long
term. In fact, during the fourth exposure session, the patient’s level of dis-
tress was very minimal.
Dismantling Studies
Dismantling studies, which examine the individual effects of specific treat-
ment procedures in multicomponent therapy programs, have addressed
three questions with respect to ERP. First, what are the differential effects of
exposure and response prevention? Second, how do these individual treat-
ment components compare to the complete ERP package? Third, is adding
exposure in imagination to situational (in vivo) exposure superior to situa-
tional exposure alone?
Differential Effects of Exposure and Response Prevention. Two stud-

ies that examined the separate effects of exposure and response prevention
found similar results (Foa, Steketee, Grayson, Turner, & Lattimer, 1984; Foa,
Steketee, & Milby, 1980). For example, Foa et al. (1984) randomly assigned 32
OCD patients (all with contamination obsessions and washing rituals) to one
of three treatment groups: exposure only, response prevention only, or the
combination (ERP). At posttreatment, patients in the exposure-only group
evidenced greater reductions in contamination fears than did those in the re-
98 CHAPTER 5
sponse-prevention-only group. In contrast, response prevention was supe-

rior to exposure in reducing washing rituals. These results suggest that
exposure and response prevention have differential effects on OCD symp-
toms: Response prevention is superior to exposure in decreasing compulsive
rituals, and exposure is superior to response prevention for decreasing ob-
sessional fear.
Exposure With Response Prevention vs. the Individual Treatment Pro-

cedures. Foa et al.’s (1984) study also revealed an additive effect of com-
bining exposure and response prevention. As shown in Fig. 5.2, ERP was
more effective than either of its individual components and led to the great-
est short- and long-term reduction of anxiety and urges to ritualize. To ex-
plain this finding, Foa et al. (1984) proposed that response prevention helps
render information learned during exposure more incompatible with the
patient’s expectations. For example, without response prevention, a patient
who repeatedly practices exposure to public bathrooms, yet does not con-
tract herpes, may attribute the nonoccurrence of herpes to her continued
compulsive washing. In this case, the maladaptive beliefs that bathrooms
are dangerous and washing rituals prevent herpes will persist. However, if
response prevention is implemented along with exposure, good health can-
not be attributed to washing rituals and thus the patient’s overestimates of
risk must change.
Imaginal and in Vivo Exposure. As discussed in previous chapters,

anxiety-evoking stimuli in OCD are not limited to external cues. Indeed,
most patients experience intrusive anxiety-evoking thoughts, images, ideas,
or impulses that elicit excessive anxiety and therefore must also be dealt with
in ERP. Whereas exposure to tangible fear cues such as dirt or unlucky num-
bers can be conducted in vivo (real life), confrontation with imagined disas-
ters obviously cannot. A woman afraid of causing fires, and therefore
constantly checking light switches, can be exposed in vivo by requiring her to
leave lights on. However, she cannot be exposed to actually causing a fire as a
result of not carefully checking. Confrontation with such situations must,
therefore, be conducted in imagination. It follows from Foa and Kozak’s
(1986) proposition regarding the importance of matching the exposure stim-
ulus with the patient’s fear that obsessional fears of disastrous consequences
should improve when imaginal exposure is added to in vivo exposure.
To examine the additive effect of imaginal exposure, Foa, Steketee,
Turner, and Fischer (1980) assigned 15 OCD patients with checking com-
pulsions to either 10 daily sessions of ERP with all exposure conducted in
vivo, or a similar regimen of ERP that incorporated both situational and
imaginal exposure. Imaginal exposure consisted of repeated and pro-
longed confrontation with thoughts of anxiety-evoking scenes related to
particular obsessional fears. For example, a woman who performed rituals
FIG. 5.2. Differential effects of exposure, response prevention, and combined treat-
ment on the mean highest subjective levels of anxiety (left), and severity of rituals
(right). From “Deliberate Exposure and Blocking of Obsessive-Compulsive Rituals:
Immediate and Long-term Effects,” by E. B. Foa, G. S. Steketee, J. B. Grayson, R. M.
Turner, & P. R. Lattimer, 1984, Behavior Therapy, 15, pp. 450–472. Copyright 1984 by the
Association for Advancement of Behavior Therapy. Reprinted with permission.
to protect her family from death purposely imaged that her husband died
as a result of her failure to perform her rituals. At posttreatment, both
groups of patients improved substantially, but did not differ significantly
from one another. However, at follow-up (3 months–2.5 years), the group
that received imaginal and situational exposure maintained their improve-
ments more than did the group that had conducted only situational expo-
sure. Thus, imaginal exposure to the consequences of not ritualizing is an
important adjunct to situational exposure.
The Efficacy of ERP
Results From Meta-Analysis. Data from a large number of controlled

and uncontrolled outcome trials consistently indicate that ERP is extremely
100 CHAPTER 5
helpful in reducing OCD symptoms. A comprehensive meta-analysis of

this literature (Abramowitz, 1996) that included 24 studies conducted be-
tween 1975 and 1995 (and involving more than 800 patients) revealed very
large treatment effects as assessed by various measures of OCD. At
posttreatment, the mean effect sizes were 1.16 on self-report measures and
1.41 on interview measures. Follow-up effect sizes were similarly large:
1.10 and 1.57 for self-report and interview scales respectively. Using a dif-
ferent meta-analytic approach, Foa and Kozak (1996) calculated the per-
centage of patients in each study that were “responders” (usually defined
as achieving a pre- to posttreatment improvement of at least 30%). They
found that across 13 ERP studies, 83% of patients were responders at
posttreatment, and across 16 studies, 76% were responders at follow-up
(mean follow-up was 29 months). In concert, these findings suggest that the
majority of OCD patients who undergo treatment with ERP evidence sub-
stantial short- and long-term benefit.
Randomized Controlled Trials. Because meta-analysis combines con-

trolled and uncontrolled studies, the aggregated treatment effect sizes are
influenced by both specific (ERP procedures themselves) and nonspecific
(e.g., time, expectancy) factors and therefore may be overstated. We there-
fore examine more closely several randomized controlled trials (RCTs) that
are designed to assess the specific efficacy of ERP procedures over and
above nonspecific effects.
Interpreting the results of OCD treatment research is aided by the fact
that most studies have used the 10-item Yale–Brown Obsessive Compul-
sive Scale (Y–BOCS; Goodman, Price, Rasmussen, Mazure, Delgado, et al.,
1989; Goodman, Price, Rasmussen, Mazure, Fleischmann, et al., 1989) as
the primary outcome measure. This has not only enabled comparisons be-
tween different studies, but it has also provided readers with a means of de-
riving clinically meaningful data from study results. The Y–BOCS
(described in detail in chapter 6) yields a total score ranging from 0 (no
symptoms) to 40 (extremely severe). Scores of 0 to 7 indicate subclinical symp-
toms, 8 to 15 indicate mild OCD, 16 to 25 represent moderate
symptomatology, 26 to 30 represent severe symptoms, and 31 to 40 indicate
profound or extreme symptoms. Because the Y–BOCS is so widely used
and possesses adequate psychometric properties, I focus primarily on this
measure in the literature review presented next.
Table 5.1 summarizes the results of four RCTs that examined the effi-
cacy of ERP. Two studies compared ERP with a credible psychotherapy
control condition. Fals-Stewart, Marks, and Schafer (1993) randomly as-
signed patients to individual ERP, group ERP, or a progressive relaxation
control treatment. All treatments included 24 sessions delivered on a
twice-weekly basis over 12 weeks. Although both ERP regimens were su-
TABLE 5.1
Effects of ERP in Randomized Controlled Trials
Y–BOCS Total Score

ERP Group Control Group
Study Control Condition n Pre Post n Pre Post
M SD M SD M SD M SD
a
Fals-Stewart et al. (1993) Relaxation 31 20.2 — 12.1 — 32 19.9 — 18.1 —
Lindsay et al. (1997) Anxiety management 9 28.7 4.6 11.0 3.8 9 24.4 7.0 25.9 5.8
Van Balkom et al. (1998) Waiting list 19 25.0 7.9 17.1 8.4 18 26.8 6.4 26.4 6.8
Foa et al. (2005) Pill placebo 29 24.6 4.8 11.0 7.9 26 25.0 4.0 22.2 6.4
Note. Y–BOCS = Yale–Brown Obsessive Compulsive Scale; ERP = exposure and response prevention.
a
Standard deviation not reported in the study.
101
102 CHAPTER 5
perior to relaxation, there were no differences between group and indi-

vidual ERP. Average improvement in the ERP groups was 41% on the
Y–BOCS, and posttreatment scores fell within the mild range of severity.
In the second study, Lindsay, Crino, and Andrews (1997) compared ERP
to anxiety management training (AMT), a credible placebo treatment con-
sisting of breathing retraining, relaxation, and problem-solving therapy.
Both treatments were intensive: 15 daily sessions conducted over a
3-week period. On average, patients receiving ERP improved almost 62%
from pre- to posttreatment on the Y–BOCS, with endpoint scores again in
the mild range. In contrast, the AMT group showed no change in symp-
toms following treatment. The clear superiority of ERP over credible pla-
cebo therapies such as relaxation and AMT indicates that improvement in
OCD symptoms can be attributed to the ERP procedures themselves, over
and above any nonspecific factors such as time, attention, or expectancy
of positive outcome.
In the Netherlands, Van Balkom et al. (1998) examined the relative effi-
cacy of four active treatments and a wait-list control. Treatment condi-
tions included (a) ERP, (b) cognitive therapy (CT), (c) ERP plus
fluvoxamine, and (d) CT plus fluvoxamine. All psychotherapy involved
16 weekly sessions. As Table 5.1 indicates, ERP fared somewhat less well
in this study than in other RCTs. A likely explanation for the relatively dis-
appointing improvement rate of 32% is that the ERP protocol was less
than optimal: All exposure was conducted as homework assignments
rather than in session and under the therapist’s supervision. Moreover,
therapists were not allowed to discuss expectations of disastrous conse-
quences during the first 8 weeks of ERP because this would have over-
lapped substantially with CT procedures.
Finally, Foa et al. (2005) conducted a multicenter double-blind RCT ex-
amining the relative efficacy of (a) intensive (15 daily sessions) ERP (includ-
ing in-session exposure), (b) clomipramine (CMI), (c) combined treatment
(ERP + CMI), and (d) pill placebo. ERP produced a 50% Y–BOCS reduction,
which was far superior to the effects of pill placebo. Moreover, endpoint
Y–BOCS scores fell within the mild range of OCD severity. ERP was also
more effective than CMI, but not CMI + ERP (which was equivalent to ERP
alone). Overall, the findings from RCTs suggest that ERP produces substan-
tial and clinically meaningful improvement in OCD symptoms and that
symptom reduction is due to the specific effects of these treatment proce-
dures and not to nonspecific or “common” factors of psychotherapy.
COGNITIVE THERAPY
Enthusiasm for ERP is dampened somewhat by the 13% to 25% refusal rate
among patients (Foa et al., 1983; Stanley & Turner, 1995), which if consid-
ered along with the additional 15% to 25% discontinuation and failure rates
reported in many studies, suggests room for improvement. Some clinicians
and researchers have turned to CT approaches to address shortcomings of
ERP because cognitive techniques incorporate less prolonged exposure to
fear cues and have led to advances in the treatment of other disorders such
as depression and panic disorder (e.g., Jones & Menzies, 1997b). The basis
of CT is the rational and evidence-based challenging and correction of
faulty and dysfunctional thoughts and beliefs that underlie emotional up-
set (Beck & Emery, 1985). As you recall from earlier chapters, individuals
with OCD hold characteristic faulty beliefs that lead to obsessive fear. It is
these beliefs that are targeted in CT, including overestimates of the proba-
bility and severity of danger and misinterpretations of intrusive thoughts
as having implications for responsibility for harm (D. A. Clark, 2004).
Delivery of CT
CT typically begins with the therapist presenting a rationale for treatment

that incorporates the notion that intrusive obsessional thoughts are normal
experiences and not harmful or indicative of anything important. Problems
with OCD are thought to arise because of how the patient appraises his or
her intrusions as significant in a way that is distressing (e.g., thoughts of vi-
olence are equivalent to committing violent acts). Misappraisal of intru-
sions in this way leads to preoccupation with the unwanted thought as well
as responses such as avoidance and safety behaviors that unwittingly
maintain the obsessional preoccupation and anxiety.
The experienced clinician may recognize that this conceptualization of
OCD parallels the established cognitive-behavioral formulation of panic
disorder proposed by D. M. Clark (1986). This model proposes that indi-
viduals with panic disorder experience innocuous arousal-related physi-
cal sensations (e.g., racing heart), which they misinterpret as indicating
that some catastrophic internal event is taking place (e.g., a heart attack).
The therapeutic implication is that correcting the way physical sensations
are perceived will reduce panic. Similarly, the cognitive formulation of
OCD assumes that unwanted intrusive thoughts are normal (Rachman &
de Silva, 1978), and that it is their misinterpretation as signs of possible
danger that underlies OCD. The rationale for the use of CT procedures is
therefore that OCD symptoms may be reduced by helping the patient cor-
rectly view his or her unwanted intrusions as nonthreatening and not
needing to be controlled.
Various techniques are used to help patients correct their erroneous ap-
praisals, such as didactic presentation of educational material and Socratic
dialogue aimed at helping patients recognize and correct dysfunctional
thinking patterns. Behavioral experiments, in which patients enter situations
104 CHAPTER 5
that exemplify their fears, are often used to facilitate the acquisition of cor-
rective information about the realistic risks associated with obsessional
fears. Although the rationale for behavioral experiments in CT is somewhat
(but not altogether) different than the rationale for exposure exercises in
ERP, there is a good deal of procedural overlap.
Van Oppen and Arntz (1994) outlined a 16-session CT program for OCD
that was aimed specifically at modifying overestimates of threat and per-
ceptions of inflated responsibility associated with obsessions. Steps in this
intervention included: (a) considering obsessive intrusions as stimuli, (b)
identifying and challenging anxiety-provoking thoughts associated with
obsessions with Socratic questioning, (c) changing the dysfunctional as-
sumptions to nondistressing ideas, and (d) behavioral experiments. van
Oppen and her colleagues later found that their CT program was effective
in reducing OCD symptoms (Van Oppen et al., 1995).
Jones and Menzies (1997b) developed a separate CT program specifi-
cally for patients with contamination and washing symptoms. Their
eight-session treatment called Danger Ideation Reduction Therapy (DIRT)
consisted of procedures designed to reduce expectations of danger con-
cerning feared contaminants. Components included (a) cognitive restruc-
turing along the lines of Beck (1976), (b) watching filmed interviews with
people regularly exposed to feared stimuli (e.g., nurses who are exposed to
blood, bank tellers who handle money), (c) presentation of results from mi-
crobiological experiments, (d) presentation of corrective information re-
garding rates of illnesses and the effects of hand washing, (e) discussions
about the probability of feared catastrophes, and (f) practice with focusing
attention away from threat cues (i.e., attentional training). In an RCT with
21 patients, Jones and Menzies (1998) found that DIRT was superior to wait
list (Jones & Menzies, 1998), thus indicating the utility of this program.
CT Versus ERP
How does the efficacy of CT measure up to that of ERP for ameliorating

OCD symptoms? Six studies have addressed this question by directly com-
paring variants of the two treatments. In two early investigations,
Emmelkamp and colleagues compared rational emotive therapy (RET,
which is a form of CT) to ERP (Emmelkamp & Beens, 1991; Emmelkamp,
Visser, & Hoekstra, 1988). RET (Ellis, 1962) involved identifying anxi-
ety-evoking thoughts (e.g., “Not washing my hands would be 100% aw-
ful”), challenging the basis of these thoughts, and replacing them with
alternative beliefs and assumptions that do not lead to anxiety; however, no
behavioral experiments were performed. Exposure in the ERP condition
was completely self-controlled, meaning patients completed all exposure
practice on their own as homework assignments. In both studies, RET and
self-controlled ERP produced roughly similar results. Limitations of these

studies included the relatively small sample sizes and use of an ERP format
that was less than optimal (no therapist-supervised exposure). In addition,
these investigations were conducted before the Y–BOCS was available.
Given the problems with these studies, it is difficult to draw from them firm
conclusions regarding the relative efficacy of ERP and RET.
Four additional studies that used the Y–BOCS compared contemporary
cognitive interventions similar to Van Oppen and Arntz’s (1994) program
to variations of ERP. The results of these investigations are summarized in
Table 5.2 and discussed next. Van Oppen et al. (1995) randomly assigned
patients to either 16 sessions of CT or 16 sessions of self-controlled ERP.
Both treatments led to an improvement in OCD symptoms and CT was
more effective than ERP (Y–BOCS reductions of 53% and 43%, respec-
tively). Importantly, the brief and infrequent therapist contact (weekly
45-minute sessions), along with reliance on patients to manage all exposure
practice on their own, likely accounted for the relatively modest effects of
ERP in this study. Moreover, CT involved behavioral experiments that re-
sembled exposure, which blurred the distinction between the two study
treatments. Only after behavioral experiments were introduced (at the
sixth session) did symptom reduction in the CT group approach that of
ERP. Thus, it is possible that the exposure component of behavioral experi-
ments is key to the efficacy of CT. Using a sample that overlapped with van
Oppen et al.’s, Van Balkom et al. (1998) found no significant difference
between CT with behavioral experiments and self-controlled ERP.
Cottraux et al.’s. (2001) study seems to provide the fairest comparison
between CT and an adequate ERP regimen. Both treatments involved 20
hours of therapist contact over 16 weeks. CT was based on Salkovskis’s
(1985) cognitive model of OCD and included psychoeducation, modifica-
tion of unrealistic interpretations of intrusive thoughts (i.e., cognitive re-
structuring), and behavioral experiments to test dysfunctional
assumptions (both in session and for homework). ERP involved thera-
pist-supervised and homework exposure and complete response preven-
tion. As shown in Table 5.2, the two programs produced comparable
outcomes at posttreatment (Y–BOCS reductions = 42%–44%). Interestingly,
ERP resulted in changes in cognitions (e.g., TAF) that were not explicitly ad-
dressed in therapy. At 1-year follow-up, patients treated with ERP had con-
tinued to improve from their posttreatment status (follow-up Y–BOCS =
11.1), whereas this was not the case with CT (follow-up Y–BOCS = 15.0). Fi-
nally, McLean et al. (2001) compared the two treatment approaches as con-
ducted in group settings. Patients received 12 weekly 2.5-hour group
sessions (6–8 participants per group) of either CT (similar to the program
used by Cottraux et al.’s [2001] study) or ERP involving in-session and
homework exposures. Both treatments were more effective than a wait-list
TABLE 5.2
106
Comparisons Between Contemporary CT and ERP
Y–BOCS Total Score

CT Group ERP Group
Study Comments n Pre Post n Pre Post
M SD M SD M SD M SD
Van Oppen et al. (1995) No therapist-supervised 28 24.1 5.5 13.3 8.5 29 31.4 5.0 17.9 9.0
ERP
Van Balkom et al. (1998) Patients overlapped with 25 25.3 6.6 13.5 9.7 22 25.0 7.9 17.1 8.4
Van Oppen et al. (1995)
Cottraux et al. (2001) Both treatments included 30 28.6 5.1 16.1 8.2 30 28.5 4.9 16.4 7.8
exposure-like procedures
McLean et al. (2001) All treatment in groups 31 21.9 5.8 16.1 6.7 32 21.8 4.6 13.2 7.2
Note. Y–BOCS = Yale–Brown Obsessive Compulsive Scale; CT = cognitive therapy; ERP = exposure and response prevention.
control condition, and ERP was associated with greater improvement than
CT at both posttreatment (40% and 27% Y–BOCS reductions, respectively)
and follow-up (21% and 41% Y–BOCS reductions).
Although the results of several comparison studies suggest that ERP
and CT were of similar efficacy for OCD, one should not conclude that
well-executed ERP is only as effective as CT. Particularly in the earlier
studies, both ERP and CT yielded minimal improvements in OCD symp-
toms. The efficacy of ERP was likely attenuated by the use of suboptimal
procedures, such as the lack of therapist-supervised exposure. Moreover,
CT programs were likely enhanced by behavioral experiments, which
probably have similar effects to supervised exposure. Using meta-ana-
lytic methods, we found that behavioral experiments improve the efficacy
of CT for OCD (Abramowitz, Franklin, & Foa, 2002). Thus, CT may have
been systematically advantaged, and ERP systematically disadvantaged,
in these investigations.
The Addition of CT to ERP
Perhaps the addition of CT can enhance the effects of ERP. To examine this
possibility, Vogel, Stiles, and Götestam (2004) conducted a controlled study
in which 35 individuals with OCD were randomly assigned to receive ei-
ther ERP plus CT (n = 16) or ERP plus relaxation (n = 19). Relaxation was
added as a placebo procedure to control for the effects of adding additional
techniques to ERP. For 12 patients, a 6-week wait list preceded active ther-
apy. Treatment entailed 12 twice-weekly 2-hour sessions with 90 minutes
dedicated to therapist-supervised exposure, and the remaining 30 minutes
for either CT or relaxation. Response prevention was partial: Patients were
required not to ritualize for 2 hours following exposure. Results indicated
that both therapy programs were superior to wait list. Among treatment
completers, Y–BOCS scores for the ERP + CT group were reduced from 25.1
to 16.4, and for the ERP + REL group, from 23.4 to 11.3 posttreatment. At
1-year follow-up, the ERP + CT group had a mean Y–BOCS score of 13.3,
and the ERP + REL group had a mean score of 10.2. Statistical analyses indi-
cated a nonsignificant trend toward superiority of ERP + REL at posttreat-
ment, but this difference disappeared at the follow-up assessment.
Importantly, the inclusion of CT was useful in reducing dropout. Thus,
there appear to be benefits to incorporating CT techniques along with
ERP—perhaps CT techniques improve the acceptability of ERP.
Combining CT procedures with ERP might be particularly helpful for in-
dividuals high on the unacceptable thoughts OCD symptom dimension. In
a controlled study, Freeston et al. (1997) obtained excellent results with a
treatment package that entailed (a) education about the cognitive-behav-
ioral model of OCD; (b) ERP consisting of in-session and homework expo-
108 CHAPTER 5
sure to intrusive thoughts using audio loop tapes and refraining from
neutralizing behaviors; and (c) CT targeting exaggerated responsibility,
perfectionism, and inflated estimates of the probability and severity of neg-
ative outcomes. Compared to a wait-list control group, treated patients
achieved substantial improvement: Among all patients (n = 28) Y–BOCS
scores improved from 23.9 to 9.8 after an average of 25.7 sessions over 19.2
weeks. Moreover, patients retained their gains at 6-month follow-up: The
mean Y–BOCS score at follow-up was 10.8. This study demonstrates that
ERP and CT can be successfully combined in the treatment of a presentation
of OCD that had previously been considered resistant to psychological
treatment (Baer, 1994).
Clinically speaking, just as exposure adds to the benefits of CT
(Abramowitz, Franklin, & Foa, 2002), cognitive techniques surely play a
critical role in ERP. It is unfortunate that most published accounts of ERP
(e.g., Kozak & Foa, 1997) fail to fully describe the informal cognitive pro-
cedures that likely contribute to its efficacy. For example, patients often
need to be persuaded that the evocation of fear that occurs during ERP
will be beneficial for them in the long term. As I describe in later chapters,
encouraging patients to engage in treatment often relies heavily on dis-
cussions about dysfunctional beliefs, the consequences of risk taking, the
costs of avoidance behavior, and the futility of attempts to gain complete
certainty via compulsive ritualizing. Importantly, the research reviewed
previously suggests that discussions about mistaken cognitions should
accompany, rather than replace, systematic prolonged and repeated ther-
apist-supervised exposure. Thus, in the CBT program I outline in Part II of
this volume, the role of CT is primarily to pave the way for ERP exercises.
That is, cognitive interventions are used to encourage patients to take ac-
ceptable risks (i.e., to undertake ERP exercises) that will help weaken their
dysfunctional beliefs.
Acknowledging the overlaps in implementation and beneficial effects of
treatment procedures derived from behavioral (ERP) and cognitive (CT)
formulations of OCD, it has become conventional to collectively describe
these procedures as “cognitive-behavioral therapy.” Therefore, when refer-
ring generally to treatment programs incorporating variations of ERP and
CT, I use the term CBT. Yet when referring to specific techniques and proce-
dures used in treatment, I continue to apply the most descriptive terms
available (e.g., CT, ERP).
THE EFFECTIVENESS OF CBT: BEYOND THE BOUTIQUE
Whereas numerous RCTs substantiate the efficacy of ERP and CT in well-

controlled academic research settings and specialty clinics (i.e., “bou-
tiques”), some authors have cautioned that results from such rigorously
conducted studies may not generalize to typical service settings (e.g.,

Silbershatz in Persons & Silberschatz, 1998). For example, RCTs fre-
quently exclude patients with comorbid conditions to achieve homoge-
nous diagnostic samples. Yet people with OCD often suffer from
comorbid mood and anxiety disorders. RCTs often exclude patients who
have failed the treatments under study. Yet, most people with OCD have
lengthy treatment histories. Thus, RCT patient samples may not be repre-
sentative of treatment-referred outpatients who present with multiple
problems. Other differences between RCTs and routine clinical practice
include rigorous therapist training and supervision, manualization of
therapy (including a fixed number of sessions), and random assignment.
It is no wonder that many practicing clinicians doubt whether the treat-
ments found efficacious in highly controlled studies do not work as well
with “typical” OCD patients as encountered in routine practice.
A promising solution to this apparent generalizability problem is effec-
tiveness research in which empirically supported treatments are evaluated
in clinical service contexts with representative patients and treatment pro-
viders. Four effectiveness studies have examined CBT for OCD as deliv-
ered in nonresearch settings. Kirk (1983) reported on 36 OCD patients
treated by non-research-oriented behavior therapists in England. Therapy
was neither manualized nor time limited, yet generally involved variations
of ERP procedures. Kirk reported that over 75% of these patients were at
least moderately improved at posttreatment, and 81% had sought no fur-
ther treatment at follow-up (between 1–5 years). Unfortunately, no stan-
dardized outcome measures were used to assess outcome, thus it is difficult
to ascertain the clinical significance of the reported improvement.
My colleagues and I (Franklin, Abramowitz, Foa, Kozak, & Levitt, 2000)
conducted a large effectiveness study in which we examined outcome for
110 consecutively referred individuals with OCD who received ERP on a
fee-for-service outpatient basis. Treatment was intensive—15 daily ses-
sions over 3 weeks—and no individuals were excluded for reasons of age,
comorbidity, previous treatment failure, or medical problems. In fact, half
of the sample had comorbid Axis I or Axis II diagnoses and 61% were medi-
cation nonresponders. Patients were only denied ERP if they were actively
psychotic, abusing substances, or suicidal (all reasons not to begin ERP in
any setting; see chapter 7). The results were encouraging: Mean Y–BOCS
scores improved from 26.8 to 11.8 (60% reduction in OCD symptoms).
Moreover, only 10 patients dropped out of treatment prematurely.
Although the Franklin et al. (2000) study demonstrated that unselected
OCD patients respond well to CBT, the therapy setting was not naturalistic:
Treatment took place in an anxiety disorders specialty clinic where many of
the therapists were highly experienced with ERP, or received regular super-
vision from ERP experts. In addition, the intensive treatment regimen was
110 CHAPTER 5
highly demanding and unlikely to be used in most outpatient settings. To

address these issues, Warren and Thomas (2001) reported on 26 individuals
with OCD treated in a private practice psychotherapy clinic with ERP and
formal cognitive techniques. Treatment sessions were held weekly for 1
hour and the total number of therapy hours across patients varied (M = 16.4
hours). Thirty-two percent of the patients in this study had comorbid con-
ditions and 50% had previously received treatment for their OCD. Results
were highly consistent with Franklin et al.’s (2000) study: Y–BOCS scores
improved from 23.0 to 11.6 (48% reduction in OCD symptoms).
In a multicultural naturalistic study, Friedman et al. (2003) presented
treatment outcome results for a community sample of African American
(n = 15), Caribbean American (n = 11), and White (n = 36) patients with
OCD. Therapy involved twice-weekly 45- to 90-minute sessions (M = about
20 sessions) of ERP and termination was decided by the clinician when it
appeared that maximal gains had been achieved. Treatment was informed
by an ERP manual, yet therapists were not required to adhere strictly to the
protocol if specific patient difficulties required alternate interventions. Al-
though treatment was effective in reducing OCD and depressive symp-
toms, many patients reported significant residual symptoms after therapy:
Mean Y–BOCS scores for African American patients were 23.5 (pretreat-
ment) and 17.2 (posttreatment; 27% reduction), and for Whites were 26.03
(pretreatment) and 17.65 (posttreatment; 23% reduction). There were no be-
tween-group differences in treatment outcome. The authors attributed the
reduced effectiveness of ERP in this study to the use of less frequent treat-
ment sessions (twice weekly compared to daily), although Warren and
Thomas (2001) obtained better results with a once-weekly ERP regimen.
Figure 5.3 compares the pre- and posttreatment Y–BOCS mean scores re-
ported in effectiveness studies to those from RCTs. As can be seen, the effec-
tiveness study samples—which contained individuals with substantial
comorbidity and histories of treatment failure who received therapy in
nonresearch contexts—fared comparably to the highly selected “rarified”
samples treated under controlled conditions in RCTs. This indicates that
the substantial and clinically significant effects of CBT for OCD are trans-
portable from research to clinical contexts.
IMPACT OF CBT ON FUNCTIONAL DISABILITY
This chapter has emphasized CBT’s effects on OCD symptoms; however,

OCD is associated with significant disability and therefore diminished
quality of life. Disability in this context refers to the extent to which the per-
son’s occupational, social, and family functioning are impaired by OCD
symptoms. Data collected from 66 patients in our OCD specialty clinic us-
ing the Sheehan Disability Scale (SDS; Sheehan, 1983) indicate that persons
FIG. 5.3. Effects of CBT as measured by the Yale–Brown Obsessive Compul-

sive Scale in randomized controlled trials and effectiveness studies.
with OCD report much more disability compared to a normative sample,

and that increased disability is related to the severity of OCD, general anxi-
ety, and depressive symptoms. Moreover, as is shown in Fig. 5.4, patients
had made significant improvements in functionality immediately follow-
ing an 8-week (16 twice-weekly sessions) course of CBT. Although this is
good news to be sure, these improved scores on the SDS remained above
those of the normative sample. Thus, it appears that although we are able to
help patients with OCD improve their functioning, we are not yet able to
get them all the way home.
FACTORS ASSOCIATED WITH THE OUTCOME OF CBT
A number of predictors of response to CBT for OCD have been identified;

most of the research has examined response to ERP. Predictor variables can
be grouped into three broad categories: (a) ERP procedural variations, (b)
patient-related characteristics, and (c) supportive factors.
ERP Procedural Variations

Meta-analytic studies have closely examined the relationship between
treatment outcome and the manner in which ERP is delivered
(Abramowitz, 1996, 1997). These results are directly applicable to clinical
practice and may be summarized as follows: First, across the literature, ERP
112 CHAPTER 5
FIG. 5.4. Effects of CBT on patients’ ratings of functional disability (N = 66).

Higher scores represent more severe disability.
programs that involved more in-session, therapist-supervised exposure

practice produced greater short- and long-term improvements compared
to programs in which all exposure was performed by the patient as home-
work assignments. Second, combining in vivo and imaginal exposure was
superior to in vivo exposure alone in reducing anxiety symptoms. Third,
programs in which patients refrained completely from ritualizing during
the treatment period (i.e., total response prevention) produced superior im-
mediate and long-term effects compared to those that involved only partial
response prevention.
If in-session exposure practice is an important component of ERP, what
is the optimal session frequency? To examine whether the robust effects of
intensive (daily) therapy are substantially compromised by reducing the
session frequency, my colleagues and I compared 15 sessions of intensive
ERP to 15 sessions of ERP delivered on a twice-weekly basis (Abramowitz,
Foa, & Franklin, 2003). Whereas intensive therapy was minimally superior
to the twice-weekly regimen immediately following treatment
(posttreatment Y–BOCS scores were 10.4 [intensive] and 12.7 [twice
weekly]), this difference disappeared at 3-month follow-up (Y–BOCS =
13.13 [intensive] and 14.25 [twice-weekly]). Results of this study suggest
that a twice-weekly therapy schedule provides clinicians with a more prag-
matic, yet equally effective, alternative to the highly demanding and often
impractical intensive protocol.
There also appears to be a relationship between adherence with ERP in-
structions and treatment outcome (Abramowitz, Franklin, Zoellner, et al.,
2002; Lax, Basoglu, & Marks, 1992). For example, we (Abramowitz,
Franklin, Zoellner, et al., 2002) found that better outcomes were associ-
ated with understanding the rationale for ERP techniques and adhering to
the therapist’s instructions for exposure practice (both in-session and
homework assignments). As discussed in subsequent chapters, these
findings suggest that it is important for clinicians to provide a compelling
explanation for using ERP procedures and to elicit the patient’s input
when developing an exposure plan.
Patient Characteristics
A number of patient characteristics have been identified as predictors of

poorer treatment response. These include the presence of extremely poor
insight into the senselessness of obsessions and compulsions (Foa, 1979;
Foa et al., 1999), severe depression (Abramowitz & Foa, 2000; Abramowitz,
Franklin, Street, Kozak, & Foa, 2000; Steketee, Chambless, & Tran, 2001),
GAD (Steketee et al., 2001), extreme emotional reactivity during exposure
(Foa et al., 1983), and severe borderline personality traits (i.e., borderline;
Steketee et al., 2001). Whereas some studies found that more severe OCD
symptoms predicted poorer outcome (e.g., Franklin et al., 2000), others did
not (e.g., Foa et al., 1983). However, consistent evidence is emerging to sug-
gest that patients who present with primarily hoarding symptoms respond
less well to traditional CBT techniques (Abramowitz et al., 2003;
Mataix-Cols, Marx, Greist, Kobak, & Baer, 2002).
Supportive Factors
Results have been conflicted as to whether the level of marital satisfaction

impacts the efficacy of CBT for OCD (Emmelkamp, de Haan, &
Hoogduin, 1990; Hafner, 1982; Riggs, Hiss, & Foa, 1992). What is clearer is
that hostility from relatives toward the identified patient is associated
with premature dropout from ERP and with poor response among pa-
tients who complete treatment (Chambless & Steketee, 1999). Interest-
ingly, Chambless and Steketee (1999) found that when relatives express
dissatisfaction with patients’ symptoms, but do not express personal re-
jection, such constructive criticism may have motivational properties that
enhance treatment response. This underscores the importance of educat-
ing family members about OCD and how to assist with ERP, as discussed
in subsequent chapters.
COMPARISON OF CBT AND MEDICATIONS FOR OCD

Efficacy of Pharmacotherapy for OCD
Pharmacotherapy using SRIs (clomipramine [Anafranil], sertraline
[Zoloft], fluoxetine [Prozac], fluvoxamine [Luvox], citalopram [Celexa],
114 CHAPTER 5
paroxetine [Paxil]) has been found effective for reducing OCD symptoms
in a number of double-blinded, randomized, placebo controlled trials (e.g.,
DeVeaugh-Geiss, Landau, & Katz, 1989; Montgomery et al., 1993. Studies of
SRIs suggest average improvement rates of about 20% to 40% (reductions
of about 5–8 points on the Y–BOCS; Greist, Jefferson, Kobak, Katzelnick, &
Serlin, 1995) in comparison to placebo. Meta-analytic results (Abramowitz,
1997; Greist et al., 1995) suggest that clomipramine is superior to other SRIs
(fluoxetine, fluvoxamine, and sertraline), and that the latter do not differ
from one another in their efficacy. However, it is important to point out that,
on average, posttreatment Y–BOCS scores of patients taking SRIs would
have qualified for entry to the respective studies. Long-term improvement
with SRIs is reliant on continuation of treatment because relapse occurs on
stoppage for most patients (e.g., Pato, Zohar-Kadouch, Zohar, & Murphy,
1988). A list of the medications evaluated in RCTs for the treatment of OCD
is presented in Table 5.3
Relative Efficacy of CBT and Pharmacotherapy
Given two effective treatments for OCD, researchers have attempted to ex-
amine the relative efficacy of CBT and SRIs (e.g., Cottraux et al., 1990; Foa et
al., 2005; Marks et al., 1988; Marks, Stern, Mawson, Cobb, & McDonald,
1980), although many of these studies used complex designs that confound
direct comparisons between these two forms of treatment. An exception is
the large multisite study by Foa et al. (2005) in which 122 patients were ran-
domly assigned to treatment by (a) ERP, (b) clomipramine, (c) the combina-
tion of ERP and clomipramine, or (d) pill placebo. ERP treatment lasted 12
TABLE 5.3
Medications Evaluated for Use With OCD
Brand Name Generic Name Manufacturer Effective Dose

Anafranila Clomipramine Novartis Up to 250 mg/day
a
Luvox Fluvoxamine Solvay Up to 300 mg/day
a
Paxil Paroxetine GlaxoSmithKline 40–60 mg/day
Prozaca Fluoextine Lilly 40–80 mg/day
a
Zoloft Sertraline Pfizer Up to 200 mg/day
Effexor Venlafaxine Wyeth-Ayerst 75 mg/day
Celexa Citalopram Forest Up to 60 mg/day
a
Approved by the U.S. Food and Drug Administration for the treatment of OCD.
weeks (4 weeks of intensive treatment followed by 8 weekly maintenance

sessions) and involved in-session (therapist-supervised) and homework
exposure along with complete response prevention. Clomipramine treat-
ment lasted 12 weeks. Immediately following treatment, all active thera-
pies were superior to placebo, and ERP (mean 50% Y–BOCS reduction) was
superior to clomipramine (mean 35% Y–BOCS reduction). Important cave-
ats for these findings are that the active phase of ERP was intensive (daily
treatment sessions), provided by expert therapists, and that patients with
comorbid conditions (e.g., depression, anxiety disorders) were excluded.
Thus this sample of patients, and the psychological treatment they re-
ceived, were not highly representative of typical clinical practice.
COMBINING CBT AND MEDICATION

IN THE TREATMENT OF OCD
Although the concurrent use of medication and psychotherapy is common

in clinical settings, relatively few studies have examined whether this ap-
proach affords advantages over monotherapy with either CBT or SRIs.
Three different outcomes are possible with combination treatment for
OCD. The desired outcome is, of course, a synergistic effect in which com-
bined therapy is superior to either CBT or SRIs alone. This could occur if
adding one treatment increases the magnitude of response to the other. A
second possibility is that medication and CBT add little to each other. This
would be the case if either form of therapy were sufficiently powerful that
the other had little room to contribute. Third, it is conceivable that one treat-
ment detracts from the efficacy of the other. This could happen, for exam-
ple, if patients attributed their improvement to taking medication and
subsequently failed to comply with CBT procedures.
For the most part, the available studies suggest that simultaneous treat-
ment with CBT and SRIs yields superior outcome compared to SRI mono-
therapy, but not compared to CBT alone (Cottraux et al., 1990; Foa et al.,
2005; Franklin, Abramowitz, Bux, Zoellner, & Feeny, 2002; Hohagen et al.,
1998; Marks et al., 1988; Marks et al., 1980; O’Connor, Todorov, Robillard,
Borgeat, & Brault, 1999; Van Balkom et al., 1998). That is, adding medication
to CBT does not improve the effectiveness of CBT. One exception was re-
ported by Hohagen et al. (1998), who found that combined ERP and
fluvoxamine offered an advantage over ERP monotherapy for seriously de-
pressed OCD patients. Importantly, many of the available studies have lim-
itations. For example, some did not use reliable outcome measures such as
the Y–BOCS, sample sizes in some investigations were too small to detect
modest differences between treatments, and many studies excluded pa-
tients with comorbidity—perhaps the very patients who would show the
116 CHAPTER 5
greatest benefit from combined treatment. The use of CBT to augment

medication treatment is discussed next.
CBT AS AN ADJUNCT TO PHARMACOTHERAPY
Recall that on average, the effects of medication leave many patients clini-
cally symptomatic. Four investigations, all of which used the Y–BOCS as an
outcome measure, have examined whether supplemental CBT results in ad-
ditional benefit in cases where patients with OCD experience only partial (or
no) improvement following one or more adequate trials of SRIs. The results
of these studies are presented in Table 5.4 and briefly summarized next.
Simpson, Gorfinkle, and Liebowitz (1999) offered twice-weekly ERP (17
sessions) to six individuals who had shown only minimal improvement de-
spite at least 12 weeks on an adequate dose of an SRI. At the completion of
ERP, scores on the Y–BOCS were substantially further reduced, indicating
that ERP augments the effects of SRIs in medication-resistant patients. Sim-
ilar results were reported by Kampman, Keijsers, Hoogduin, and Verbank
(2002), who conducted 12 sessions of CBT with 14 individuals who evi-
denced less than 25% symptom reduction after 12 weeks on fluoxetine. In a
third study, my colleague Lori Zoellner and I (Abramowitz & Zoellner,
2002) examined whether these findings reported extended to OCD patients
with primarily obsessions and covert (e.g., mental) neutralizing strategies.
Following 15 sessions of twice-weekly CBT, the six patients in our study im-
proved substantially compared to the minimal gains they had made during
the 12 weeks on an SRI before beginning CBT. Finally, Tolin, Maltby,
Diefenbach, Hannan, and Worhunsky (2004) selected 20 individuals with
TABLE 5.4
Summary of Studies Examining the Effects of CBT
for Medication-Resistant Patients With OCD
Y–BOCS Mean Score

Postmedication/
Study N Premedication pre-CBT Post-CBT
M SD M SD M SD
Simpson et al. (1999) 6 23.8 2.6 12.2 4.3
Kampman et al. (2002) 9 28.1 5.6 25.7 5.3 15.0 6.5
Abramowitz & Zoellner (2002) 6 23.3 2.7 8.7 4.5
Tolin, Maltby, et al. (2004) 15 25.2 5.7 15.9 9.0
Note. Y–BOCS = Yale–Brown Obsessive Compulsive Scale; CBT = cognitive-behavioral therapy.

OCD who had a high rate of comorbid psychological diagnoses and who
had not responded adequately to multiple adequate medication trials. Af-
ter a 1-month wait-list period, these patients received 15 sessions of ERP.
Results indicated a statistically significant drop in OCD symptoms follow-
ing psychological treatment although posttreatment Y–BOCS scores re-
mained somewhat high. Still, those who completed the study maintained
their gains as far out as 6 months after the end of treatment (follow-up M
Y–BOCS score = 18.7).
Together, these studies indicate that CBT is an appropriate strategy to
use for OCD patients who have residual symptoms despite having tried
SRI medications. The clinical implications of this research are substantial
because medication is the most widely available (and therefore the most
widely used) form of treatment for OCD, yet it typically produces only
modest improvement. This means that psychotherapists are very likely to
encounter patients who have already attempted treatment with medica-
tion, yet desire additional help. Thus, an important role for CBT is that it
works well for medication nonresponders.
II
How to Conduct Consultation
and Treatment for OCD
6
Consultation I:
Diagnosis and Assessment
Psychological consultation entails obtaining a thorough assessment of a

patient’s problem and providing education, information, and recommen-
dations to that individual and his or her family or support network
(Brown, Pryzwansky, & Schulte, 2001). Consultative services are based on
the consultant’s education, training, and experience, as well as on knowl-
edge of the relevant scientific literature. This chapter provides a detailed
description of how to conduct a diagnostic interview, assess the nature
and severity of OCD symptoms, and provide feedback to the patient re-
garding his or her symptoms. Collection and discussion of this informa-
tion constitutes one portion of the initial consultation that should precede
therapy. The second portion of the consultation, described in chapter 7, in-
volves discussing and recommending an effective treatment. The assess-
ment procedures covered in this chapter can be conducted over a 2- to
3-hour period, and may be divided across multiple sessions if necessary.
More time may be required in complex cases or for therapists new to
working with individuals with OCD. The case of Susan T., described next,
will be used to illustrate the consultation and treatment procedures
throughout the second part of this book.
121
122 CHAPTER 6
Susan T., a 33-year-old elementary school teacher, had been married for 6
years. She and her husband, Steve, have a 3-year-old son, Brian, and a
3-month-old infant, Jennifer. Susan’s primary care physician has referred her
to a psychologist because of persistent washing and checking rituals that
were not responding to various serotonergic medications. Susan had also un-
dergone numerous trials of talk therapy that had not been particularly helpful
in alleviating her symptoms.
OVERVIEW AND PURPOSE OF ASSESSMENT
Assessment is an ongoing and conceptually driven pursuit where theories

of the causes, maintenance, and treatment of OCD determine what is im-
portant to evaluate. Initial assessment begins with a clinical interview to
substantiate a diagnosis of OCD, identify possible comorbid conditions,
and rule out problems that are sometimes mistaken for OCD. Next, the con-
tent and severity of the individual’s obsessions and safety-seeking behav-
iors are determined. The presentation of OCD symptoms, range of
comorbid psychopathology, and impact of the disorder on the individual’s
functioning vary widely from patient to patient. Thus, assessment should
encompass the individual’s level of functioning, support network, and
treatment goals. Understanding this broad context helps the clinician iden-
tify factors that might exacerbate or ameliorate OCD symptoms, or impact
adherence to treatment recommendations. It also helps with recognizing
additional forms of psychopathology that warrant clinical attention or that
might impact treatment planning.
DEVELOPING A THERAPEUTIC RELATIONSHIP

Careful assessment provides an excellent opportunity to begin developing an
alliance with the patient and engaging him or her in the process of goal setting.
Many patients with OCD come to their initial consultation embarrassed about
their symptoms, perhaps having hidden their obsessional thoughts and com-
pulsive rituals from friends or relatives for many years. In such cases, the clini-
cian can destigmatize these symptoms by recasting them as manifestations of
a clinical disorder, rather than eccentric or “mad” behavior. It might help to
point out that about 1 in 40 people have OCD, and to provide examples of ob-
sessions and compulsions reported by others. In contrast to those who conceal
their symptoms, other patients will have become caught up in vicious cycles of
mutual irritation or coercion with family members. Here, the assessment pro-
cess provides a chance to encourage collaboration and cooperation in imple-
menting a jointly agreed on treatment program.
CONSULTATION I: DIAGNOSIS AND ASSESSMENT 123
IMPORTANCE OF ONGOING ASSESSMENT

Continually assessing the nature and severity of OCD and related symp-
toms throughout the course of treatment assists the therapist in evaluat-
ing whether, and in what ways, the patient is responding. This is
consistent with the emphasis on objective measurement of treatment ef-
fectiveness within evidence-based practice. It is not sufficient for the clini-
cian simply to think, “He seems to be less obsessed,” or “It sounds like she
has cut down on her compulsions”; or even for the patient (or a relative) to
report that he or she “feels better.” Instead, progress should be assessed
systematically by comparing current functioning against the baseline ob-
tained at the outset of treatment. Thus, periodic assessment using the
psychometrically validated instruments described later in this chapter
should be conducted to clarify in what ways treatment has been helpful
and what work remains to be done.
ASSESSMENT AS PSYCHOEDUCATION
Helping the patient understand why his or her seemingly bizarre and
senseless thoughts and behaviors persist despite strong resistance en-
hances the value of assessment for the patient. For example, learning that
most everyone normally experiences odd or upsetting unwanted
thoughts helps normalize these experiences. Frequently, patients fail to
see the connections between their obsessional fears and their avoidance or
safety-seeking behaviors. Pointing out that these responses are means of
coping with obsessional fear helps validate such behaviors, even if they
are excessive; for example, “I know you think it’s a bit strange, but if you
are afraid of catching germs from dead bodies, I can see why you’d want
to shower after driving past a cemetery.” Linking avoidance and safety
behaviors to obsessional thoughts in this way also makes the patient in-
creasingly aware that his or her behaviors are consistent and predictable.
In turn, this awareness helps patients identify their obsessions and com-
pulsions more accurately.
ESTABLISHING THE DIAGNOSIS OF OCD
The clinician should begin with unstructured inquiry into the present
symptoms, history, family issues, and feelings about treatment. This infor-
mation will guide the structured component of the assessment described
later in this chapter.
124 CHAPTER 6
Assessing the Chief Complaint and History
The assessor’s initial job is to determine whether the patient’s symptoms fit
into the category of OCD and whether comorbid conditions are present.
Chapter 2 provides useful guidelines for distinguishing between OCD and
other disorders that, although just as disturbing, are not the same as OCD. It
is useful to begin by asking the patient to describe his or her chief complaint
and purpose for coming to the session. The patient might also be asked to de-
scribe a typical day, highlighting the frequency, intensity, and duration of
OCD symptoms. The interviewer can probe for information about how the
problem is managed and how symptoms interfere with functioning. Table
6.1 contains a list of additional questions for eliciting more information about
the presence of obsessions, compulsions, avoidance, and other safety-seek-
ing strategies. Information about the onset, historical course of the problem,
comorbid conditions, social and developmental history, and personal and
family history of psychiatric treatment should also be obtained.
Susan T. described intense fears of becoming ill from germs, particularly

from bodily fluids and secretions such as urine and sweat. She awakened at
4 a.m. each morning to complete a 2-hour bathroom routine before leaving
for work. Her ritualistic behavior included extensive decontamination of
the toilet and shower using heavy-duty cleansers, the need for half of a roll
of toilet paper to wipe herself when using the toilet, and a 45-minute shower
routine that included washing her body according to specific rules she had
devised. Hand washing occurred throughout the day and Susan was spend-
ing over an hour cleaning the dishes after dinner. She also described a fear of
fires and break-ins, and often got “stuck” checking that doors and windows
were locked, and that appliances were off and unplugged. At work she re-
checked paperwork extensively, which often caused her to be late for pick-
ing up her son from day care. Soon after the birth of her daughter, Susan
began having scary unwanted thoughts of hurting this child. For example,
she was afraid to carry Jennifer for fear of dropping her down the stairs, and
at times, asked her husband, Steve, to bathe the baby because of unwanted
thoughts about drowning her in the bathtub. Although Susan was able to
work, she was constantly behind in her paperwork and felt as if things were
getting worse.
Insight
When assessing the patient’s ability to recognize the senselessness of his or

her symptoms, the clinician should keep in mind that this capability often
fluctuates. Some individuals will willingly concede that their obsessional
fears are irrational, yet they still cause distress and urges to perform rituals.
A smaller group firmly believes that their obsessions are realistic and com-
pulsive rituals serve to prevent feared disasters. In most patients, however,
the strength of belief changes depending on the situation, making it diffi-
TABLE 6.1
Examples of Open-Ended Questions to Help
in Assessing the Presence of OCD Symptoms
• How often do the obsessional thoughts come to mind? How long do they last?
• What kinds of activities or situations trigger the obsessional thoughts or urge
to ritualize?
• What kinds of activities do you avoid to prevent yourself from worrying
about accidents or mistakes?
• What do you do to avoid coming into contact with ________ (triggers)?
• What do you do to prevent yourself from thinking thoughts that upset you
or make you worried?
• When you come into contact with ________ (trigger), what do you do?
• How many times a day do you feel the urge to ______ (insert safety-seeking
ritual)?
• How long does each ritual last?
• After you have completed this safety-seeking ritual how do you feel? How
anxious are you?
• When you are worrying about accidents, mistakes, or harm, how do you
assure yourself that things are OK?
• What precautions do you take to make sure you don’t make terrible
mistakes, have an accident, or hurt anyone?
• What do you do to keep yourself from acting on unwanted thoughts?
• If you were unable to ________ (give examples of rituals), how would you
feel? What are you afraid might happen?
• How much do you think these rituals are senseless or excessive?
• How often do you resist or delay your rituals? What happens when you try?
• How else are these fears and rituals interfering with your life? What are you
avoiding because of your fears?
• How does your family react to your symptoms? What do they think of your
situation?
• Are other people involved in your rituals? Do they help you avoid feared
situations?
125
126 CHAPTER 6
cult to pin down the precise degree to which they recognize the symptoms
are irrational. For example, in the session, a patient might be able to state
that the risk of acting on an intrusive impulse to stab someone is quite low.
However, when the impulse occurs at home as triggered by watching a
sleeping child, it might evoke intense fear that the dreaded consequences
will occur. Assessment of insight is illustrated by the following exchange
between Susan and her therapist:
Therapist: Can you tell me how likely it is that a fire would start if you
left the toaster plugged in while you were away from your
house for a few hours?
Susan: I wouldn’t do that. I definitely think it would cause a fire.
Therapist: So, you are saying that there is a 100% chance that leaving the
toaster plugged in will cause a fire; right?
Susan: Well … I guess so.
Therapist: Hmmm. Most people leave appliances like toasters plugged
in even when they are not using them. For example, in my
house, the toaster stays plugged in all the time whether some-
one is home or not. In fact, it’s probably been plugged into the
electrical outlet continuously for several years. But what
you’re saying is that by now, my house should have burned
down; and probably lots of others’ homes too. How do you
explain that house fires are less common than that, and that
fire prevention guidelines don’t say that you should unplug
toasters every time you leave the house?
Susan: Hmm. I hadn’t thought about it that way. Maybe it’s not 100%
likely. Maybe it’s less likely, like 10% or even less.
Because Susan was able to notice the inconsistency in her thinking and re-
vise her probability estimate (although it remained excessively high), she
was considered to have good insight into the senselessness of her symptoms.
Mood
Because most individuals with OCD also suffer from depressive symptoms
it is important to assess mood state. Clinicians should inquire about the
chronological history of mood complaints to establish whether such symp-
toms should be considered as a primary diagnosis or as secondary to OCD
symptoms. Primary depression develops in parallel with OCD, and might
precede OCD onset. In contrast, when depressive symptoms develop sub-
sequent to OCD, and when the patient describes being depressed about
having OCD, the depression is considered secondary to OCD.
Social Functioning
Clinicians should assess the degree of impairment in leisure and social,
family, and occupational or academic functioning. Where appropriate,
this information should be incorporated into the treatment plan so that
difficulties can be addressed in the appropriate context. As an example,
Susan experienced difficulties grading students’ paperwork and entering
these grades into her computer because she repeatedly checked for possi-
ble errors. Thus, treatment could include practicing performing these
tasks at work without checking. In cases where the patient is not working
(i.e., a temporary leave of absence), work situations may be simulated as
closely as possible.
History
Circumstances surrounding the onset of the problem and the course of
symptoms should be assessed. Typically, symptoms wax and wane over
time, yet some patients describe a general worsening over the years. Many
patients cannot describe the particulars surrounding the origin of their
OCD symptoms, either because onset was not discrete or because the
symptoms began so long ago that the memory has since faded. Fortunately,
it is not essential to know the exact causes or predisposing factors of OCD
for CBT to be successful. If previous treatment has been unsuccessful, ob-
tain the patient’s explanation for this failure, and discuss how the planned
course of therapy will differ in ways that might yield a better response.
Previous Treatment
It is important to collect information about previous attempts to treat OCD
symptoms to determine whether the patient has received adequate treat-
ment. Perhaps he or she has been prescribed medications that are not
known to be helpful with OCD, or low dosages of potentially helpful medi-
cines. Many patients seek CBT because they wish to augment any gains
achieved with medication, or so that they can discontinue using drugs alto-
gether. Another issue is whether psychodynamic or analytic psychother-
apy has been tried. If so, former therapists might have told the patient that
his or her OCD was caused by intrapsychic conflicts from childhood, and
that insight into the nature of such phenomena is required for improve-
ment. If this is the case, the clinician should explain that there is no evidence
OCD is caused by internal conflicts, nor is there evidence that working on
resolving conflicts reduces symptoms.
If the patient has previously received CBT, a determination should be
made of whether or not the treatment regimen was satisfactory. Adequate
CBT involves prolonged and repeated exposure to the patient’s most
128 CHAPTER 6
feared situations along with complete response prevention. Many pa-

tients describe therapy in which they were never exposed to their most
feared stimuli, in which response prevention was only partial (e.g., stop-
ping some rituals but not others), or in which therapy sessions occurred
infrequently (e.g., every 2 weeks) allowing for a return to avoidance and
safety-seeking behaviors between sessions. Appendix A includes the
OCD Treatment History Form, which clinicians can use to determine
whether a patient has previously received an adequate trial of CBT. If a
satisfactory CBT regimen has occurred, closely examining the reasons for
failure may shed light on potential obstacles to the current treatment. For
example, was the patient reluctant to try difficult exposure tasks? Did he
or she not adhere to response prevention instructions? If compliance and
adherence were not issues in previous failures, it might mean that the pre-
vious treatment plan was deficient.
Medical History and Review of Systems
It is useful to obtain a brief medical history. What (if any) major medical is-
sues or treatments has the patient had? If the patient has not seen a doctor
within the last year, a yearly check-up should be recommended. Has OCD
or its treatment been discussed with the patient’s general physician? Signif-
icant medical concerns should be addressed with a physician before begin-
ning treatment for OCD. In addition, it is important to assess the following
areas: daily and weekly exercise amounts, daily caffeine use, and daily al-
cohol and drug use. If substance usage is a concern, it should be determined
whether the use of alcohol or drugs is associated with OCD symptoms. As
we will see in the next chapter, substance abuse and dependence can impact
decisions about treatment for OCD.
Family Issues
The therapist should ask the patient about his or her family of origin.
What was growing up like? Did relatives suffer with OCD or other anxiety
disorders? Did parents or other authority figures (e.g., teachers, clergy)
reinforce extreme regidity, cleanliness, order, ideas about danger, or the
importance of thoughts? Although there is no way to verify whether such
experiences set the stage for the development of OCD, they may lead to
core beliefs that influence how certain situations and stimuli are inter-
preted. For example, one man with fears of contamination from blood
said that, as a young boy, he recalled an incident in which his mother be-
came very upset that there was blood on her pillow. She resorted to wash-
ing all of the bed linens several times to make sure the blood was cleaned
away because “blood is dangerous.”
Assessment should also address relatives’ emotional responses to the

patient’s OCD symptoms. In some families, relatives are highly critical and
express hostility toward their loved one with OCD. This may be manifested
as meddling or intrusiveness into the patient’s daily activities. Asking pa-
tients to rate how critical relatives are using a scale from 1 (not at all critical)
to 10 (extremely critical) can help determine whether family issues require
further assessment or intervention (Chambless & Steketee, 1999).
In other families, relatives may enable or accommodate patients’ OCD
symptoms by helping with checking and cleaning rituals, providing fre-
quent reassurance to ease obsessional anxiety, and by avoiding situations
that evoke obsessional distress (e.g., contact with contaminants). In one ex-
treme example, the parents of a 30-year-old patient purchased a new home
to alleviate their son’s fears of contamination following an incident in
which dirty laundry had fallen on the floor in their former home. In most
cases, accommodation occurs either to avoid confrontation over OCD
symptoms, or because family members do not want to see loved ones suffer
with extreme anxiety. However, such behavior reinforces obsessional fear
and, if not addressed, adversely impacts treatment outcome.
Including family members in the assessment process and gaining their
perspective on the problem can shed light on family reactions and the de-
gree to which symptoms are accommodated. Sometimes relatives observe
avoidance and safety-seeking behavior that the patient has not reported.
This also affords an opportunity to view how the relatives respond to the
patient. Are they supportive, constructively critical, or hostile? In an
open-ended fashion, relatives should be asked about the extent to which
they participate in the patient’s compulsive rituals and avoidance habits.
How do they respond when repeatedly asked questions for reassurance?
What consequences do they fear if symptoms are not accommodated (e.g.,
will the patient leave home, commit suicide, or “go crazy”)? To what extent
are the family’s activities modified because of OCD symptoms? The clini-
cian should explain that the purpose of involving family members in the in-
terview is to collect information from a variety of viewpoints. We typically
invite relatives into the session after all information has been collected from
the patient, but before reviewing this information or presenting
recommendations for treatment.
Individual Strengths and Areas of Difficulty

To help attain a more global impression of the patient, he or she can be
asked what he or she views as personal strengths and shortcomings. Has
she or he ever had legal difficulties? How does the person view himself or
herself in light of the fact that he or she has OCD? How does he or she per-
ceive his or her ability to manage symptoms? Other questions should per-
tain to strengths and difficulties with managing OCD symptoms. That is,
130 CHAPTER 6
which situations, fears, or rituals are he or she best able to resist or control;
and which do he or she most struggle to manage?
Motivation for Treatment
Because compliance with CBT procedures requires a great deal of effort on

the patient’s part, it is critical to assess his or her motivation for therapy.
Was it his or her or someone else’s idea to seek treatment? If the patient is
presenting on his or her own volition, what was it that drove him or her to
ask for help now? If others have “forced” the patient into seeking therapy,
what is the patient’s understanding of why this is the case? Determination
of how hard an individual is willing to work to reduce OCD symptoms may
present clinicians with a challenge, and straightforward questioning is not
always the best strategy because individuals may be tempted to give the so-
cially desirable response (e.g., “very hard”). As we will see in chapter 7, one
strategy is to describe CBT procedures and ask the patient whether he or
she would agree to participate. Miller and Rollnick (2002) described some
excellent ways of conceptualizing and assessing motivation for change.
These motivational interviewing techniques are directly applicable to the
treatment of OCD.
Structured Diagnostic Interview
If it appears from the unstructured assessment that OCD symptoms are

present, a standardized diagnostic interview should be used to confirm this
diagnosis, as well as to determine the presence of any other comorbid anxi-
ety and mood disorders. A number of instruments exist for this purpose, in-
cluding the Anxiety Disorders Interview Schedule for DSM–IV (ADIS–IV;
DiNardo, Brown, & Barlow, 1994), the Structured Clinical Interview for
DSM–TR (SCID; First, Spitzer, Gibbon, & Williams, 2002), and the Mini In-
ternational Neuropsychiatric Interview (MINI; Sheehan et al., 1998). In our
clinic we use the MINI to establish diagnoses because it is a fairly brief in-
terview that possesses very good reliability and validity. The section of the
MINI for diagnosing OCD is reprinted for use in Appendix B.
The MINI confirmed that Susan met the diagnostic criteria for OCD. She rec-
ognized that her obsessional fears and compulsive rituals were excessive, and
therefore was not diagnosed with poor insight. Although Susan reported de-
pressive symptoms, these did not rise to the level of a major depressive epi-
sode. Moreover, her mood symptoms were clearly secondary to her
difficulties with OCD. She also endorsed persistent worry, but because her
worries were confined to OCD-related topics she did not meet the criteria for
generalized anxiety disorder.
ASSESSING THE TOPOGRAPHY OF OCD SYMPTOMS
The broad range of possible obsessions and safety-seeking behaviors as

discussed in Part I present a challenge during assessment. Because patients
often do not spontaneously report all of their symptoms the clinician is ad-
vised to use the Symptom Checklist of the Yale–Brown Obsessive Compul-
sive Scale (Y–BOCS–SC; see Appendix C) to gain a more thorough and
comprehensive picture of the symptom presentation. The Y–BOCS–SC is a
very useful clinical interview that begins with instructions for providing
the patient with practical definitions of obsessions and compulsions to help
in identifying these symptoms. Next, the interviewer proceeds through a
checklist of more than 50 common obsessions and compulsions that the pa-
tient indicates as currently present, absent, or present only in the past. Clini-
cians should ask for examples of each symptom the patient endorses to
confirm that only OCD symptoms are recorded. The role of family mem-
bers in performing particular compulsions can also be assessed during ad-
ministration of the Y–BOCS–SC (e.g., Do other people in your family help
with your checking?). After completing the checklist, the clinician and pa-
tient generate a brief list of the most severe (primary) obsessions, compul-
sions, and OCD-related avoidance behaviors to be targeted in treatment.
A limitation of the Y–BOCS is that it largely assesses symptoms on a su-
perficial descriptive level without concern for functionality. For example,
patients are asked whether or not they have an excessive showering or
grooming routine. Although it is important to know whether such rituals
exist, it is also meaningful to understand the relationship between these rit-
uals and the patient’s obsessions. That is, some patients’ ritualistic showers
involve washing various parts of their body very thoroughly to reduce con-
tamination fears. For other individuals, however, showers might be ritual-
istic because the patient has to repeat certain behaviors a certain number of
times (or avoid performing them in certain numbers) to magically prevent
feared disasters such as car accidents or plane crashes. The point here is that
to gain a true understanding of the patient’s symptoms, the clinician must
inquire about the functionality of symptoms endorsed on the
Y–BOCS–SC—not simply whether or not the symptom is present. A related
issue is that care should be taken to ensure that only OCD symptoms are
rated as such. The Y–BOCS–SC contains a number of items (e.g., hair
pulling) that are not genuine obsessions or compulsions.
The Y–BOCS–SC identified numerous specific obsessions and compulsions

for Susan. She endorsed contamination obsessions and washing compul-
sions, obsessions of making mistakes that would lead to terrible outcomes
and checking compulsions, and unacceptable thoughts and mental rituals.
Primary obsessions, compulsions, and avoidances included:
132 CHAPTER 6
Primary Obsessions Primary Compulsions Avoidance

1. Contamination from 1. Excessive bathroom 1. Public
body waste rituals restrooms
2. Responsibility for 2. Excessive ritualized 2. Trash cans
mistakes and disasters washing
3. Violent, horrific impulses 3. Checking locks, 3. Bathroom floors
appliances, papers
MEASURING SYMPTOM SEVERITY
Measuring the severity of current symptoms provides a way of quantify-

ing the patient’s experience and comparing his or her level of distress
and impairment with the population of OCD sufferers at large. It also
helps the clinician offer a rationale for considering treatment and dis-
cuss what might be expected in terms of treatment response. A
multitrait, multimethod approach to assessing symptom severity is sug-
gested. This involves the use of clinician-administered and self-report
instruments that tap into various facets of OCD, depression, general
anxiety, and functional disability. Table 6.2 includes a list of recom-
mended measures. These measures, as well as other interviewing tech-
niques, are discussed in the text that follows.
TABLE 6.2
Suggested Instruments for the Assessment of OCD Severity
and Related Symptoms
No. of Assessment Symptom

Measure Items Method Focus
Y–BOCS severity scale 10 Interviewer OCD
Obsessive Compulsive Inventory–Revised 18 Self-report OCD
Brown Assessment of Beliefs Scale 7 Interviewer Insight in OCD
Hamilton Depression Scale 17 Interviewer Depression
Beck Depression Inventory 21 Self-report Depression
Beck Anxiety Inventory 21 Self-report General anxiety
Sheehan Disability Scale 3 Self-report Functional
disability
Note. y–BOCS = Yale–Brown Obsessive Compulsive Scale.

Clinician Administered Measures
Severity of Obsessions and Compulsions. The Y–BOCS severity scale

is regarded as the gold standard measure of OCD symptoms (Appendix C).
It contains 10 items (5 that assess obsessions and 5 that assess compulsions),
each of which is rated on a 5-point scale from 0 (no symptoms) to 4 (extremely
severe). Items address (a) the time occupied by current symptoms, (b) inter-
ference with functioning, (c) associated distress, (d) attempts to resist ob-
sessions and compulsions, and (e) the degree of control over symptoms.
Scores on each of the 10 items are summed to produce a total score ranging
from 0 to 40. In most instances, scores of 0 to 7 represent subclinical OCD
symptoms, those from 8 to 15 represent mild symptoms, scores of 16 to 23
relate to moderate symptoms, scores from 24 to 31 suggest severe symp-
toms, and scores of 32 to 40 imply extreme symptoms. In clinical research, a
score of at least 16 is commonly used to identify patients with symptoms se-
vere enough to warrant inclusion in studies on OCD.
The Y–BOCS is unique among measures of OCD in that it is sensitive to
multiple aspects of symptom severity independent of the number or types
of different obsessions and compulsions. However, the clinician must be
careful to ensure that only bona fide OCD symptoms are rated. Because ad-
ministration of the Y–BOCS checklist and severity scale may require up to
45 minutes (perhaps more in complex cases), some clinicians opt to use the
scale as a self-report measure. However, patients often require direction in
responding to Y–BOCS items, so this practice is not recommended. More-
over, the discussion spawned by administration of the instrument as a
semistructured interview provides pertinent information. Therefore, the
time required to properly use the scale as a clinical interview may be con-
sidered well spent. Used in this way, the Y–BOCS also has good reliability
and validity, and is sensitive to the effects of treatment (Goodman, Price,
Rasmussen, Mazure, Delgado, et al., 1989; Goodman, Price, Rasmussen,
Mazure, Fleischmann, et al., 1989).
Insight Into OCD Symptoms. The Brown Assessment of Beliefs

Scale (BABS; Eisen et al., 1998) is a brief continuous measure of insight
that has good reliability, validity, and sensitivity to change (see Appendix
D). Administration begins with the interviewer and patient identifying
one or two of the patient’s specific obsessional beliefs that have been of
significant concern over the past week (prior use of the Y–BOCS to iden-
tify target symptoms is helpful). Examples include, “If I don’t carefully
check the garbage, I will discard important items by mistake,” “I will get
herpes if I use a public toilet,” and “I will act on the unwanted impulse to
molest children.” Next, individual items assess the patient’s (a) convic-
134 CHAPTER 6
tion in this belief, (b) perceptions of how others view this belief, (c) expla-
nation for why others hold a different view, (d) willingness to challenge
the belief, (e) attempts to disprove the belief, (f) insight into the senseless-
ness of the belief, and (g) ideas or delusions of reference. Only the first six
items are summed to produce a total score. Eisen, Phillips, Coles, and
Rasmussen (2004) reported a mean total score of 8.38 (SD = 4.14) on the
BABS among 64 individuals with OCD.
Depressive Symptoms. Because the majority of individuals with OCD

report mood symptoms, and as many as half will meet criteria for a depres-
sive disorder at some point in life (Crino & Andrews, 1996a), assessment of
mood complaints should be routine. The Hamilton Rating Scale for Depres-
sion (HRSD; Hamilton, 1960) is a well-studied, semistructured interview
that measures cognitive (e.g., feelings of guilt), affective (e.g., current mood
state), and somatic (e.g., appetite, sleep) aspects of depression. The scale
has adequate psychometric properties and is sensitive to the effects of treat-
ment (Hedlund & Vieweg, 1979). It is used widely for assessing depressive
symptoms in OCD patients.
Self-Report Measures
It would be convenient if clinicians could rely on patients to provide reli-

able and valid answers to queries about the frequency, intensity, and du-
ration of their obsessive fears and compulsive behaviors. However, as
this is not always the case, psychometrically validated self-report instru-
ments should be used to supplement the clinical interview. Self-report
measures have the advantage of using carefully worded questions that
are consistent over time. Moreover, they allow the clinician to compare
the patient’s responses to well-established norms for other people with
and without OCD. Accordingly, questionnaires are valuable for screen-
ing purposes, to corroborate information obtained in a clinical inter-
view, and to monitor symptom severity during treatment, but not as a
substitute for careful clinical interviewing.
Severity of Obsessions and Compulsions. Numerous self-report in-

ventories have been developed to measure the content and severity of
OCD symptoms (for a comprehensive review see Taylor, Thordarson, &
Sochting, 2002). The difficulty is that many were devised to measure the
more quintessential features of OCD, such as washing and checking com-
pulsions. Therefore, not all of these instruments adequately assess the full
range of obsessions and compulsions. An exception is the Obsessive Com-
pulsive Inventory (OCI; Foa, Kozak, Salkovskis, Coles, & Amir, 1998), a
42-item measure that assesses the frequency and distress associated with
a comprehensive range of obsessional and compulsive phenomena. Some

practical problems with the OCI (it is long and the scoring procedure is ar-
duous) led to a subsequent revision, the OCI–R (see Appendix E), which
consists of only 18 items (Foa, Huppert, et al., 2002). Each item (e.g., I
check things more often than necessary) is rated on a 5-point scale (0–4) of
distress associated with that particular symptom. The OCI–R has six sub-
scales—washing, checking, ordering, obsessing, hoarding, and neutraliz-
ing—each containing three items that are summed to produce subscale
scores (range = 0–12). A total score (range = 0–72) may be calculated by
summing all 18 items. The OCI–R is psychometrically sound (Foa et al.,
2002) and is useful for measuring response to treatment (Abramowitz,
Tolin, & Diefenbach, 2005). A cutoff score of 15 can often differentiate
OCD patients from nonpatients.
Depression and Anxiety. The Beck Depression Inventory (BDI; Beck,

Ward, Mendelsohn, Mock, & Erlbaugh, 1961) is one of the most widely used
measures of depressive symptoms in research and clinical settings. It con-
tains 21 items that measure the cognitive, affective, and somatic features of
global distress. The BDI has good psychometric properties, is sensitive to
treatment, and is easy to administer and score. Patients typically need
about 5 minutes to complete the scale and scores of 20 or greater usually in-
dicate the presence of clinical depression.
The Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988) is
an ideal measure of general anxiety that enjoys widespread clinical and re-
search use. It consists of 21 items that assess the severity of clinical anxiety
symptoms over the past week on a 4-point (0–3) severity scale. Items mea-
sure physiological responses (e.g., sweating), affective states (e.g., scared),
and anxious cognitions (e.g., fear of losing control). The BAI was designed
to assess anxiety symptoms independently from depressive symptoms. It
has good reliability and validity (Beck et al., 1988) and requires about 5
minutes for patients to complete.
Functional Disability. The Sheehan Disability Scale (SDS; Sheehan,

1983) is a brief and face valid measure of functional impairment that is rou-
tinely used in clinical research. It consists of three 0-to-10 ratings of the ex-
tent to which symptoms interfere with work, social, and family life.
Susan’s Y–BOCS score was 27, placing her OCD symptoms in the severe
range. She had a score of 6 on the BABS, indicating good insight, and a score of
10 on the HRSD, suggesting subclinical depressive symptoms. A number of
self-report inventories had been completed before the assessment session and
Susan’s responses on these instruments were consistent with the information
obtained through the clinical interviews. Susan indicated that while her so-
136 CHAPTER 6
cial life was only moderately impaired by her OCD symptoms, her work and
family life were seriously handicapped.
PROVIDING FEEDBACK AND ADDRESSING FREQUENTLY

ASKED QUESTIONS
Very often, patients are accompanied to the initial consultation by a close

relative or friend (e.g., spouse, parent) who is interested in being included
in the assessment. To preserve confidentiality and maximize the patient’s
comfort with disclosing what are often perceived as “bizarre” or embar-
rassing symptoms, we recommend conducting the initial interview indi-
vidually, and including relatives (at the patient’s discretion, of course)
when it comes time to discuss the results of the interview and provide edu-
cation and recommendations. Before inviting relatives or friends into the
session, the clinician and patient should discuss whether there are any
symptoms that the patient prefers not be discussed in front of others.
Susan’s initial interview was conducted individually with the therapist.

However, because Susan’s husband, Steve, had expressed interest in being in-
volved with treatment, the therapist suggested that he be invited into the of-
fice to hear the summary of Susan’s symptoms and to raise any questions or
concerns that he had. Susan agreed and said that Steve knew about all the de-
tails of her symptoms; thus it was all right to openly discuss them.
To address the patient’s (and relatives’) questions about his or her

problem, feedback should include an explanation of (a) the diagnosis of
OCD and scores on relevant assessment measures, (b) a brief functional
description of the patient’s particular OCD symptoms, and (c) a brief re-
view of the etiological theories of OCD (making treatment recommenda-
tions is also an important part of this process, but is discussed in chapter
7). The clinician should be prepared to address these issues directly and
honestly. The following are some exemplary ways to review clinical im-
pressions and discuss the nature of OCD with patients. Susan’s case is
again used as an example, but clinicians can adapt these discussions for
any patient with OCD.
Summarizing the Interview Results
Patients are typically eager to find out the assessor’s impressions of their
problem. Thus, feedback should begin with a review of the interview re-
sults. First, the clinician should summarize the information that has been
collected and discuss the diagnosis of OCD.
Therapist: Now that I have collected information about your symptoms, I

would like to review my impressions with you. First, the prob-
lems you are describing fit into the category of obsessive–com-
pulsive disorder, or OCD for short. You might already know
this, but it is important for me to interview you carefully to
make an accurate diagnosis because this will influence my rec-
ommendations for treatment. Your main problem areas in-
clude fears of contamination and washing and cleaning
rituals, fears of making mistakes and repetitive checking, and
upsetting thoughts about your baby girl, Jennifer. Everyone’s
OCD symptoms are a little different, yet the kinds of symp-
toms you are experiencing are fairly common ones.
To find out how severe your symptoms are, I gave you the
Yale–Brown Obsessive Compulsive Scale, or Y–BOCS for
short, which is the gold standard measure of OCD symp-
toms. Based on what you told me about your symptoms, your
score is 27 out of a possible 40. We consider this in the severe
range of OCD. However, you seem able to recognize that
your fears and rituals are senseless, even though they don’t
seem senseless when you are anxious. I also asked you about
symptoms of depression, and based on how you described
your mood at this time, it appears that although you feel
down from time to time, you do not meet criteria for clinical
depression right now. How does this fit with your experience
of these problems?
Explaining the Symptoms of OCD
Patients and their confidants often have misunderstandings about the

nature of OCD. Therefore, it is appropriate to begin providing psychoedu-
cational material to correct such misperceptions. For example, most lay-
people define obsessions as thoughts, and compulsions as behaviors. As
we have seen, this is an inaccurate way to differentiate between such phe-
nomena. Instead, patients should learn to distinguish between obsessions
and compulsions on the basis of whether they evoke or reduce anxiety.
Clarifying this functional relationship will help the patient better under-
stand his or her own symptoms and how they can be reduced with CBT. Us-
ing the patient’s own symptoms to illustrate the phenomenology of OCD,
the clinician can begin to instill an understanding of the problem as a set of
patterns that adhere to the rational laws of learning. As patterns, the symp-
toms can be weakened with CBT.
138 CHAPTER 6
Therapist: I want to review with you some information about OCD so

that we are all on the same page when it comes to how we un-
derstand this complex problem. First, OCD is part of a larger
group of disorders called the anxiety disorders. It is also one
of the more common psychological disorders, affecting about
1 in 40 people. As you know, it can have a very negative im-
pact on life functioning.
As we have talked about during the evaluation, OCD in-
volves two major symptoms: obsessions and compulsions.
Obsessions are unwanted thoughts that may be triggered in
different situations, such as your thoughts of getting sick
when you use the bathroom, the idea that you graded a stu-
dent’s paper incorrectly, and your unwanted thoughts about
hurting Jennifer. The most important aspect of obsessions is
that they provoke anxiety. Compulsions, on the other hand, are
urges to do things like rituals to decrease obsessional anxiety.
Rituals can be visible behaviors like washing and checking,
or they can be subtle mental actions like having to think a spe-
cial “good thought.”
Obsessions and compulsions are related. So, each time you
have obsessive fears about germs, your reaction is to wash
your hands to reduce your fear. It is human nature to try to
avoid feeling anxious, or do something that reduces the dis-
comfort if it can’t be avoided. What you have learned to do to
restore a state of comfort is to wash and clean, and to avoid
situations to minimize exposure to feared contaminants; for
example, by avoiding public bathrooms. Similarly, you have
developed a pattern of rechecking paperwork before hand-
ing it back to your students to deal with your doubts that you
made a mistake. Checking reassures you that you haven’t
made any terrible errors, and this reassurance makes you feel
better. Now, as you know, compulsive rituals often bring you
some relief from obsessional fear—but the relief is only tem-
porary. Before long, obsessional fears return and you get
stuck ritualizing over and over. This is because the feeling of
relief you experience after you complete a ritual is very pow-
erful. So, the more relief you feel, the more you want to ritual-
ize the next time you feel anxious. You have learned to use
rituals to reduce your obsessional fears. They make you feel
safe. Do you see the way that your obsessions and rituals are
connected in a pattern?
Susan: Yes. No one has ever explained it to me this way before, but it
makes a lot of sense.
Therapist: I’m glad it makes sense. So, what you need is to learn a way of
dealing with obsessional thoughts that doesn’t involve doing
rituals. Rituals are traps.
Susan: I would probably go insane if I didn’t wash or check. I feel like
something very bad would happen.
Therapist: That’s because you usually do the rituals to make you feel
safe. But, realistically, the risk of harm is very low in these sit-
uations—you said so yourself. It’s just that you have learned
that ritualizing is a quick, easy, and very powerful way to re-
duce anxiety. Unfortunately, the ritualizing prevents you
from overcoming your obsessional fear.
Susan: If I learned to do rituals, can I “unlearn” them?
Therapist: Yes, but it requires help. We know from research studies
that OCD symptoms do not typically go away on their
own. In fact, most people who seek treatment for OCD say
that things tend to get worse over time; although, depend-
ing on stressful events in your life, your symptoms may im-
prove or get worse from day to day or week to week. So, I
highly recommend that you consider receiving treatment
for your OCD symptoms.
Discussing Etiological Theories of OCD
Naturally, patients often speculate as to what causes problems such as

OCD. Many form their own theories, perhaps influenced by consumer-ori-
ented educational materials they have encountered, or information pro-
vided by previous professionals they have seen. Because CBT more or less
requires the adoption of a particular conceptual model, it is important to
begin socializing the patient to this approach from the outset. This often in-
volves correcting faulty perceptions of what causes OCD and why certain
treatments will or will not hold promise.
Susan said that a psychiatrist once told her that OCD was caused by a “chemi-
cal imbalance” in her brain that was similar to, but not as severe as, that which
causes schizophrenia. This was highly disconcerting to Susan, who had been
a psychology major in college and imagined that people with schizophrenia
often lived out their lives isolated and institutionalized. Susan had also been
told that to treat OCD required medications that correct the imbalance of sero-
tonin in her brain, and that because people with OCD have many problems
with brain functioning, she should expect to suffer from OCD symptoms for
the rest of her life. Susan was hopeful that there was a better prognosis. Still,
she was somewhat skeptical of what she perceived as “yet another try at psy-
chotherapy.” During the consultation, the clinician began laying the founda-
tion for a cognitive-behavioral conceptualization by confidently presenting
the following information.
140 CHAPTER 6
Susan: If my OCD symptoms are learned patterns, why did my psy-

chiatrist tell me that OCD is a brain disease?
Therapist: I don’t know about that, but I can tell you that there has been a
lot of research on the causes of OCD and presently there are no
clear answers. There are probably many different factors that
interact to cause OCD. But, even though we don’t know for
sure what causes OCD, we do have some good leads. Two the-
ories that have been well studied are the biological theory and
the learning theory. Let me talk for a minute about each theory.
First, the biological theory proposes that OCD is a medical
or genetic disease that is caused by a problem with the neuro-
transmitter serotonin, which works in the brain and nervous
system. Usually people take this to mean that having OCD is
like having other medical conditions, like diabetes; the body
is simply not producing the right amounts of certain chemi-
cals. Lots of research has been conducted in which the brains
of people with OCD have been compared to the brains of peo-
ple without OCD. While some studies have found differences
that point to deficient serotonin levels in OCD, just as many
studies have not found any differences. These inconsistent
findings suggest that it is premature to assume at this point
that OCD is caused by serotonin problems. Plus, this expla-
nation is overly simplistic because it ignores the fact that our
experiences in the world affect the very complex chemical
systems and neural pathways in the brain. In fact there is re-
search showing that people’s brains change when they are
treated successfully with either psychological treatment or
medication for OCD. So, the cause of OCD is probably not en-
tirely biological, although it appears that some people are
more vulnerable than others to developing anxiety problems
like OCD, and this vulnerability might be biological.
The other leading theory is that experiences people have
while growing up affect the development of OCD. For exam-
ple, someone raised in a family where the parents worried a
lot, or washed their hands a lot, could be vulnerable to getting
OCD. Some researchers think that being taught very strict
rules about how to think and behave, and how not to think
and behave, could lead to OCD; especially if these rules are
nearly impossible to follow and if there is the threat of pun-
ishment for breaking the rules. Finally, situations where a
person’s thoughts or behavior seemed to contribute to bad
luck or to a serious tragedy might play a role. For example,

let’s suppose that you think about your dog dying, and then
the next day, your dog coincidentally dies. This might make
you worry that perhaps your thoughts had something to do
with causing the dog’s death. Researchers think that such ex-
periences could trigger OCD. As with the biological theory,
there have been many studies of the learning theory. Yet there
is not enough evidence to confirm that OCD is caused en-
tirely by these environmental factors.
So, as you can see, the jury is still out on what exactly
causes OCD. The most reasonable conclusion at this time
based on the available research is that OCD is probably
caused by a complex combination of factors—biological and
environmental. One metaphor that helps people to under-
stand this is that of a blizzard. To get a severe snowstorm, the
atmosphere must have cold air and moisture. Either of these
ingredients by itself cannot produce snow. They both must be
present, but perhaps in varying amounts. The same is true for
how biology and the environment give rise to OCD. In fact,
the exact cause—how much biology versus environmental
influence is present—is probably different for each person.
So, it is not a good idea to worry about what caused your
OCD, or to blame your parents, your brain, or your genes for
creating this problem. Most likely, it is not possible to figure
this out with much accuracy.
Do we have to know about the causes of OCD to treat it ef-
fectively? The answer is “no.” But we do have to understand
the symptoms of OCD. Fortunately, we know a great deal
about these symptoms. A comparable situation is that of
treating cancer. If you went to the doctor for cancer treatment,
he or she would not be too concerned with trying to figure out
exactly why you got cancer in the first place. This is because
cancer treatments—surgery, radiation therapy, and chemo-
therapy—work based on what we have learned about how to
stop cancer cells (tumors) from growing, and this is different
from knowing exactly why the cancer started in the first
place. OCD is the same way. Through research, we now know
a great deal about the symptoms of OCD. We know how they
develop into strong patterns that are difficult to weaken with-
out the right kind of help. The goal of treatment, therefore, is
to weaken these patterns.
142 CHAPTER 6
Susan: So I don’t have a disease of my brain?

Therapist: That’s probably right. If you had real problems with your
brain, they would manifest themselves in more ways than
just OCD. You wouldn’t be able to teach, keep a marriage, or
raise children; and you’d probably have all sorts of other
problems, too. OCD is a set of maladaptive patterns that be-
come worse on their own. The treatment program that I can
offer you is based on weakening these patterns.
It is helpful to pause at this point and address patients’ questions about

the etiological theories. Regardless of which model is favored, the clinician
should emphasize the importance of understanding the function of symp-
toms and draw on specific examples of the patient’s obsessions and rituals to
highlight how obsessional thoughts and situations evoke anxiety, and how
compulsions become habitual responses because they reduce anxiety. In the
next chapter we consider factors that influence treatment recommendations
and the procedures for describing the effective forms of therapy for OCD.
7
Consultation II: Recommending
a Treatment Strategy
Treatments for OCD that have been empirically tested can be divided into
two broad categories: cognitive-behavioral and biological. CBT, which was
discussed in chapter 5, includes the use of exposure, response prevention,
and cognitive therapy techniques and can be delivered in a variety of for-
mats and settings. Biological treatments include pharmacotherapy with
SRIs and neurosurgery. The first part of this chapter provides an overview
of the CBT program described in this book. Next, I present descriptions of
the available biological treatments for OCD. The third section discusses fac-
tors to be considered when recommending a particular treatment or treat-
ments to an individual patient. The chapter ends with examples of
responses to frequently asked questions that patients and their families
raise when discussing treatment options.
OVERVIEW OF CBT FOR OCD
There are five main components of the CBT program that I outline in chap-
ters 8 through 13 of this book:
• Information gathering and case formulation.

• Cognitive therapy techniques.
143
144 CHAPTER 7
• Exposure therapy.
• Response prevention.
• Maintenance and relapse prevention techniques.
The information-gathering and case formulation phase involves

in-depth assessment of obsessional triggers; cognitive, behavioral, and
emotional responses to triggers; and the derivation of a case formulation
based on the cognitive-behavioral model of OCD described in Part I. Cog-
nitive therapy techniques, which include educational modules and meth-
ods for challenging and restructuring problematic beliefs and
assumptions, are aimed at directly weakening dysfunctional thinking pat-
terns. Exposure therapy and response prevention (ERP) form the central el-
ements of CBT. Although the primary aims of ERP include weakening
patterns of avoidance and compulsive rituals, these techniques are also a
powerful vehicle of cognitive change. Finally, relapse prevention tech-
niques include strategies for maintaining and extending treatment gains,
including methods for managing future episodes of obsessional fear.
The Recommended Treatment Regimen
The CBT regimen described here is a time-limited program that generally

consists of 16 treatment sessions of 90 minutes in length. Typically, ses-
sions are held on a twice-weekly basis with one session scheduled toward
the beginning of the week and the other occurring toward the end (e.g.,
Monday and Thursday). Spacing the sessions in this way minimizes the
intersession interval; thus, any gravitation toward dysfunctional think-
ing or behavioral habits can be addressed promptly. This program also af-
fords the patient opportunities to practice the skills learned in therapy in a
variety of settings (including in his or her own home), thus promoting the
generalization of treatment effects.
During the first two to three sessions (information gathering and case
formulation) the therapist conducts an in-depth functional assessment of
the patient’s specific triggers, and the cognitive and behavioral responses
(i.e., safety seeking) associated with OCD. The culmination of this inquiry
is the derivation of a patient-specific case formulation and treatment plan
that is based on the cognitive-behavioral model of the persistence of OCD
symptoms (see chapter 4). Simultaneously, the therapist uses educational
modules to socialize the patient to the cognitive-behavioral model, the
treatment interventions, and the goals for therapy. Psychoeducation specif-
ically addresses the normalcy of intrusive obsessional thoughts and the re-
lationship between catastrophic beliefs and anxiety. Understanding and
“buying in” to the conceptual model helps patients recognize more subtle
aspects of their OCD symptoms and increases collaboration, motivation,
CONSULTATION II: RECOMMENDING A TREATMENT 145
and compliance with later treatment interventions. The information gath-

ering phase can therefore be regarded as an exchange of information be-
tween patient and therapist. The patient, who best understands his or her
own OCD symptoms, educates the therapist about these symptoms. Simul-
taneously, the therapist, who knows how to synthesize from this informa-
tion a viable treatment plan, teaches the patient how to think about his or
her symptoms in a way that maximizes the effectiveness of therapy.
By Session 4, the treatment plan is developed and a rationale for using
ERP techniques is provided. Exposure is implemented hierarchically, be-
ginning with moderately distressing situations and stimuli. It may be help-
ful to frame ERP as a set of experiments to test the validity of erroneous
probability estimates of harm. In other instances these procedures are used
to demonstrate that anxiety recedes over time even if compulsive rituals are
not performed. Gradual therapist-supervised exposure to anxiety-evoking
situations and intrusive thoughts is planned for Sessions 4 though 16, and
homework practice is assigned for completion between sessions. Patients
are helped to refrain from safety-seeking behaviors during treatment.
Because ERP involves the purposeful evocation of obsessional fear, pa-
tients often require a great deal of encouragement to engage in such tasks,
yet how to persuade patients to persist with exposure remains more of an
art than a technology in CBT. By helping patients modify their cata-
strophic predictions about the outcome of exposure, cognitive therapy
can help convince patients of the benefits of confronting mistakenly
feared situations. Therefore, the chief role of cognitive therapy is to set the
stage for ERP tasks, which are the “active ingredients” in treatment. As
described in subsequent chapters, cognitive therapy is also used through-
out a course of CBT when the therapist identifies mistaken beliefs as barri-
ers to therapeutic exposure.
As the end of therapy draws closer, the therapist begins to incorporate
procedures to enhance the maintenance of treatment gains. These include
(a) education about the relationship between stress and OCD symptoms
and the process of relapse, (b) instruction in how to choose situations for
self-controlled exposure, (c) problem solving regarding how to spend time
that was previously occupied by OCD symptoms, and (d) scheduling
follow-up visits.
Other CBT Programs
Intensive Outpatient Treatment. A handful of OCD specialty clinics

offer intensive outpatient CBT, involving 15 daily (Monday–Friday) 90- to
120-minute sessions (e.g., Franklin et al., 2000). The first two or three ses-
sions are dedicated to information gathering and treatment planning. Next,
daily sessions incorporate therapist-supervised in vivo and imaginal expo-
146 CHAPTER 7
sure with instructions for abstinence from compulsive rituals (response

prevention). Daily exposure exercises are also assigned for the patient to
practice outside of the sessions. A relapse prevention program consisting of
four 90-minute sessions over 1 week may be applied following the inten-
sive therapy period. Relapse prevention includes (a) a discussion of lapse
versus relapse, (b) identifying stressors that could trigger OCD symptoms,
and (c) cognitive therapy. A practical advantage of intensive CBT over less
intensive treatment is that massed sessions allow for regular therapist con-
tact and rapid correction of problematic between-session avoidance or
compulsive habits. The primary disadvantage is the inherent scheduling
demands for both the clinician and the patient. Intensive outpatient CBT is
therefore an optimal program for patients seeking treatment from out of
town and those with great difficulty resisting compulsive rituals.
A number of clinical variables should guide recommendations regard-
ing treatment schedule. Daily sessions permit close supervision of expo-
sure and rapid identification of problems with adherence. This is important
because nonadherence can impede outcome. Thus intensive CBT is recom-
mended when patients report extreme difficulty with confronting feared
stimuli, poor insight, or difficulty grasping the rationale for using ERP
techniques. Missed sessions, excessive bargaining over exposure instruc-
tions, difficulty refraining from ritualizing, and involvement of family
members in avoidance and rituals are often signs that an intensive regimen
should be considered over a less intensive schedule. Because we believe it is
critical for individuals to practice self-guided exposure in a wide range of
settings, twice-weekly treatment is the default for local patients in our
clinic. Only when the obstacles just described are present do we suggest a
more intensive regimen; and very rarely would we recommend that CBT
occur on a one-session-per-week basis.
Group CBT. Conducting CBT in a group format can be helpful for

OCD (Fals-Stewart et al., 1993; McLean et al., 2001). Advantages of this ap-
proach include the support and cohesion of a group atmosphere. Potential
disadvantages include the relative lack of attention to each individual’s
symptoms, especially given the heterogeneity of OCD symptoms.
Residential CBT Programs. Although most inpatient psychiatric hos-

pitals are equipped to provide standard care for patients with OCD, pro-
gramming is often limited by the short duration of stay. Therefore, the
initial focus is often on stabilizing patients via medication and supportive
psychotherapy. Only a few specialized residential treatment programs for
severe OCD exist. Therapy typically includes individual and group CBT,
medication management, and supportive therapy for comorbid psychiatric
conditions. Length of stay may vary from a few weeks to a month or more.
One advantage of specialized residential OCD programs is that they

provide constant supervision for patients requiring help with implement-
ing treatment (i.e., conducting self-directed ERP). This may be helpful in
very severe cases hampered by functional disability, and those in which pa-
tients lack the support or assistance of family or friends. Drawbacks of in-
patient treatment include the costs and the travel. The range of situations
available for exposure practice may also be constrained by the hospital set-
ting. For example, bathrooms in the patient’s home environment cannot be
confronted until the patient returns home. This could pose problems for pa-
tients whose symptoms are triggered by particular stimuli found only in
certain places that cannot easily be transported to a hospital.
BIOLOGICAL TREATMENTS
Serotonin Reuptake Inhibitors
As reviewed in chapter 5, although they are the most widely available (and
the most widely used) treatment for OCD, SRIs typically produce a modest
20% to 40% reduction in symptoms (Rauch & Jenike, 1998). The major
strength of pharmacological treatment is its convenience. Limitations in-
clude a high rate of nonresponse (40%–60% of patients show little response),
relatively modest improvement rates, high probability that residual symp-
toms will persist, and likelihood of side effects. Additionally, once SRIs are
terminated, OCD symptoms typically return rapidly (Pato et al., 1988).
Neurosurgical Treatment
The clinician should be aware that currently, four neurosurgical procedures
are available for use with OCD patients: subcaudate tractotomy, limbic
leucotomy, cingulotomy, and capsulotomy. These operations involve sever-
ing interconnections between areas of the brain’s frontal lobes and the limbic
system. Recommended only in cases where severe and unmanageable OCD
and depressive symptoms persist despite adequate trials of all other avail-
able treatments, the risks of neurosurgery include permanent alterations in
cognitive functioning and personality. Although clinical improvement has
been observed in some cases, it remains unknown why these procedures are
only successful for a subset of OCD patients (Jenike, 2000). There is also an in-
creased risk of suicide following failure with this approach.
FACTORS TO CONSIDER
WHEN RECOMMENDING TREATMENT
Let us now turn to a discussion of the factors to be considered when decid-
ing on which treatment to recommend for a particular patient. As listed in
148 CHAPTER 7
Table 7.1, these variables may be divided into two broad categories: (a) fac-
tors that are related specifically to aspects of the patient’s presentation of
OCD, and (b) nonspecific factors.
OCD-Related Factors
Primacy and Severity of OCD Symptoms
A defining characteristic of CBT is that the techniques used in therapy

target specific symptoms. For instance, exposure procedures target ob-
sessional fear. Thus, CBT for OCD should be recommended only when
obsessions and compulsions cause clinical levels of distress and are
among the patient’s primary complaints. Because CBT programs (par-
ticularly intensive programs) require a substantial commitment to ther-
apy, patients should not initiate this treatment if they are concurrently
attending therapies likely to compete for time and energy. Examples
would include intensive therapy for substance abuse or eating disor-
ders. Commitment issues are less relevant to the use of pharmaco-
therapy. Thus, patients who have additional therapeutic undertakings
that they are unwilling to discontinue would be advised to begin with
medication until their schedule can accommodate CBT.
The clinical severity of OCD symptoms alone should not determine
whether CBT or medication is recommended as the first-line treatment.
TABLE 7.1
Factors to Consider When Recommending Treatment for OCD
OCD-related factors
Primacy and severity of OCD symptoms
Symptom presentation
Presence of feared consequences of obsessions and the degree of insight
Comorbidity with Axis I and II psychopathology
Treatment history
Nonspecific factors
Demographic characteristics
Educational level
Availability of treatment
Patient preference
Social support
There is no evidence that either treatment (or combined treatment) is more

effective for more severe obsessions and compulsions. Given the superior
short- and long-term effectiveness of CBT, and the fact that improvement is
typically achieved over less than 20 sessions, CBT should be considered be-
fore SRIs regardless of clinical severity. Greater symptom severity may ne-
cessitate a more intense regimen of whichever treatment is offered: a higher
dose of medicine or more frequent CBT sessions. In cases where patients are
practically incapacitated by their symptoms (e.g., cannot leave their home)
or present a danger to themselves or to others, residential treatment should
be recommended.
Symptom Presentation
Hoarding. As reviewed in chapter 5, accumulating evidence suggests

that hoarding symptoms are associated with poorer response to CBT
(Abramowitz, Franklin, Schwartz, & Furr, 2003; Mataix-Cols et al., 2002)
and SRIs (Mataix-Cols, Rauch, Manzo, Jenike, & Baer, 1999) typically used
with OCD. This is likely because the factors that maintain hoarding symp-
toms extend beyond those that maintain other OCD symptoms as de-
scribed in previous chapters. Because patients with primary hoarding
exhibit deficits in decision making and organizational skills, appropriate
treatment must target these areas. Hartl and Frost (1999) developed a cog-
nitive-behavioral protocol for hoarding that involves training in organiza-
tional and decision-making skills as well as some cognitive and
exposure-based techniques. Although still experimental, these newer ap-
proaches should be utilized when patients present with primarily hoarding
symptoms (Frost, Steketee, & Greene, 2003). Because the treatment tech-
niques presented in this book pertain less to hoarding than to other types of
OCD symptoms, only limited discussion of their application to hoarding
appears in subsequent chapters.
Pure Obsessions. Patients (and clinicians) may have read or been told
that mental rituals or “pure obsessions” fare less well in treatment com-
pared to when the clinical picture involves overt compulsions such as
washing and checking. However, owing to contemporary theoretical and
research advances in understanding and treating obsessions without overt
rituals (Rachman, 2003), both cognitive and exposure-based techniques
have been adapted for use with patients presenting with this symptom pic-
ture (e.g., Freeston et al., 1997). These treatment procedures are described in
subsequent chapters. Thus, the absence of prototypical compulsive behav-
ior and the presence of severe mental rituals are not reasons to defer a rec-
ommendation of CBT. To the contrary, such symptoms often respond quite
readily to cognitive and exposure-based interventions.
150 CHAPTER 7
Feared Consequences and the Degree of Insight
Whereas some individuals with OCD clearly articulate fears of disastrous

consequences associated with their obsessions (e.g., “If I touch the bathroom
floor and do not wash my hands I will become very ill”), others do not verbal-
ize specific feared outcomes (e.g., “I just wouldn’t feel right unless I ritual-
ized”). Research suggests patients who describe specific feared consequences
fare better with CBT than do those without specific fears (Foa et al., 1999).
Clinical observations and research findings indicate that patients who
have poor insight into the senselessness of their OCD symptoms improve
less with CBT than do those who recognize that their fears and safety-seek-
ing behaviors are excessive or unreasonable (Foa, 1979; Foa et al., 1999).
Perhaps it is difficult for patients who are strongly convinced that their
fears are realistic to consolidate disconfirming evidence gleaned from ex-
posure exercises. Alternatively, those with poor insight may be more reluc-
tant, because of their fears, to confront obsessional situations during
exposure therapy. Thus, adherence may be a problem for such patients. To
increase adherence to instructions for exposure, therapists might use cogni-
tive techniques to “tenderize” strongly held dysfunctional beliefs. A sec-
ond augmentative approach for patients with poor insight is SRI
pharmacotherapy. Some psychiatrists will even prescribe antipsychotic
medication for such patients despite no consistent research evidence that
this augmentation strategy produces additional benefits over mono-
therapy (e.g., Bystritsky et al., 2004; Shapira et al., 2004).
Comorbidity
Certain comorbid Axis I conditions are known to interfere with the ef-
fects of CBT. For example, seriously depressed persons with OCD may be-
come demoralized and have trouble complying with the demands of
exposure therapy (e.g., Abramowitz & Foa, 2000; Abramowitz, Franklin,
Street, Kozak, & Foa, 2000; Foa, 1979). Also, the strong emotional reactiv-
ity present in people with severe depression could interfere with habitua-
tion during exposure sessions and limit treatment gains (e.g., Foa et al.,
1983). For individuals with OCD and comorbid GAD, pervasive worry
might detract from the time and emotional resources needed to learn the
skills for managing obsessional fear (Steketee et al., 2001). Whereas highly
anxious patients, once engaged, often benefit from CBT, severe depres-
sion might be cause for postponing this approach to treatment until the
depression can be brought under control (e.g., with antidepressant medi-
cation or psychotherapy aimed at depression). Given that the
serotonergic medications used with OCD are also used in the treatment of
both depression and GAD, these drugs represent another possible recom-
mendation for patients with comorbidity.
Although research is scarce, our clinical observations suggest that psychotic

and manic symptoms, as well as active substance abuse and dependence, at-
tenuate the effects of CBT. Patients suffering from these symptoms have inter-
ference with normal perception, cognition, and judgment, which would
impede their ability to follow treatment instructions or consolidate corrective
information gleaned through exposure exercises. The use of mood-altering
substances to manage distress evoked by exposure is of particular concern be-
cause this would prevent the natural habituation of obsessional fear and the
learning of corrective information. Therefore, services aimed at bringing such
conditions under control (e.g., detoxification, antipsychotic medications)
should be sought prior to attempting CBT for OCD.
Severe personality disorders and traits can also hinder response to CBT
and medication (Steketee et al., 2001). For example, anxious (e.g., obses-
sive-compulsive personality disorder) and dramatic (e.g., histrionic per-
sonality disorder) traits might interfere with developing rapport and
adhering to instructions for EPR. However, if a therapeutic relationship
can be developed, CBT can be successful despite these traits. Clinicians
should also consider that some patients with dramatic traits gain rein-
forcement for their OCD symptoms. In such circumstances, CBT is un-
likely to succeed because patients do not perceive themselves as gaining
rewards for their efforts to reduce obsessions and rituals. Individuals
with personality traits in the odd cluster (e.g., schizotypal personality dis-
order) present a challenge to CBT because of their reduced ability to profit
from corrective information obtained during exposure or cognitive inter-
ventions. Clinicians are therefore advised to consider CBT for OCD pa-
tients with comorbid anxious or dramatic personality traits, while
heeding the potential problems discussed previously. On the other hand,
when OCD is comorbid with odd personality traits, intensive inpatient
CBT along with medication is recommended.
Treatment History
Clinical observations suggest that for the most part, patients who have
received an adequate length and dosage of one SRI (see Table 5.3 for recom-
mended doses) are unlikely to respond to others, or to combinations of dif-
ferent SRIs. Thus, for medicated patients who have not had a course of CBT,
psychological treatment is the obvious next choice. If, however, patients re-
port that they have undergone CBT, the adequacy of this therapy course
should be assessed before making additional recommendations (see Ap-
pendix A). If the previous treatment included infrequent sessions, lack of
adequate exposures, little emphasis on refraining from rituals, or if patients
were not given a clear rationale for the use of ERP techniques, an adequate
trial of CBT should be considered.
152 CHAPTER 7
There are various reasons that patients previously treated with ade-
quate CBT seek additional help. Most commonly they require “booster
sessions” to help with maintenance of earlier gains. In such cases, patients
approach therapy having already been socialized to the cognitive-behav-
ioral model and the intervention techniques, and often fare quite well.
Other individuals seek an additional CBT trial due to the failure of an ear-
lier trial. In such cases it is important to identify factors that might have
contributed to failure so that these can be addressed in the current trial.
The most common reason for unresponsiveness to exposure-based ther-
apy is nonadherence with treatment procedures; particularly, the inability
or unwillingness to confront feared stimuli or delay carrying out rituals
and other forms of safety-seeking behavior (Rachman & Hodgson, 1980).
Noncompliance with ERP procedures due to extreme fear may necessitate
the increased use of cognitive and motivational interventions to prepare
the patient for exposure.
Other, more subtle, reasons for nonresponse to CBT include the persis-
tence of subtle avoidance tactics and covert safety behaviors. For exam-
ple, one patient followed all instructions for exposure to feared
contaminants as assigned by the therapist, but then, to make response
prevention easier, avoided situations where casual exposure might occur.
Another patient was able to refrain from her overt checking behavior, but
persisted in compulsively mentally reviewing all of her actions to reas-
sure herself that she had not made any bad mistakes. This type of problem
highlights the need for patients to identify and understand the function of
their symptoms as described in earlier chapters. Response prevention re-
quires abstaining not just from overt compulsive rituals, but also from
subtle tactics (safety-seeking behaviors) used to escape from obsessive
fear. Finally, some patients make a transient, but not a permanent commit-
ment to change. They might vow (secretly) to engage in treatment during
the program, but as one patient with blasphemous obsessions told us, “In
the back of my mind, I always knew I would start the praying rituals again
the minute treatment was over.” This individual had actually made excel-
lent progress during his previous course of CBT, but relapsed within a
short time.
A history of noncompliance due to motivational factors may suggest the
need for either residential treatment or alternative methods altogether (e.g.,
medication, individual therapy for other difficulties). The motivational in-
terviewing techniques described by Miller and Rollnick (2002) can be use-
ful tools in such instances. Finally, for patients who have failed multiple
adequate trials of both pharmacotherapy and CBT, the clinician can recom-
mend individual supportive therapy, group support programs, or (if symp-
toms are unremitting and insufferable) psychosurgery.
Nonspecific Factors
Age, Gender, and Race. For different reasons, the elderly have more
difficulty with adherence to medication regimens than do young and mid-
dle-aged adults. Missed doses or overdoses may result in reduced benefit
and unpleasant side effects. Older adults may be subject to more adverse
side effects from SRIs because of reduced metabolic rates and interactions
with medicine prescribed for other conditions. Thus, CBT is the best initial
treatment option for older adults. Evidence that CBT is highly effective for
elderly individuals with OCD is accumulating (Calamari & Cassiday,
1999). Nevertheless, older individuals may feel more comfortable with
medication rather than attending outpatient psychotherapy. This issue
should be discussed openly during consultation.
Gender should not affect treatment recommendations for OCD. Never-
theless, some patients may feel more comfortable with therapists of their
same sex, especially if symptoms involve sexual (e.g., unwanted doubts
about sexual preference) or contamination (e.g., semen) concerns that pro-
voke self-consciousness. For example, a therapist of the same sex would be
necessary to accompany the patient during exposure to public restrooms.
Some members of minority groups perceive a stigma in seeking psy-
chotherapy and therefore obtain treatment, usually in the form of medica-
tion, through primary care physicians (Williams, Chambless, & Steketee,
1998). This sense of shame can also interfere with assessment and CBT by
hindering the patient’s self-report of symptoms and his or her perfor-
mance of exposure exercises. In addition, members of minority groups
may be reluctant to involve friends or relatives in their treatment (Hatch,
Friedman, & Paradis, 1996), thus leaving them without benefit of outside
support. The suggestion of residential treatment may induce further
shame for members of minority groups; thus clinicians must address this
topic with sensitivity. Although these issues may make pharmacotherapy
a better initial treatment for some patients, Williams et al. (1998) reported
clinically significant improvement for African American OCD patients
treated with CBT.
Educational Level. Successful CBT requires that the patient compre-

hend an abstract model of OCD and rationale for the treatment procedures.
Moreover, the ability to consolidate information learned during exposure
practice, complete written exercises, and implement these treatment proce-
dures independently is necessary for improvement. These skills may be dif-
ficult for individuals who are overly concrete in their thinking. Because
group CBT may proceed at a pace that is too rapid for individuals with cog-
nitive impairment or severe learning disabilities, individual therapy is rec-
154 CHAPTER 7
ommended for such patients. For those OCD patients too cognitively
impaired to comprehend or profit from CBT, it may be more fruitful to ex-
plore other forms of psychotherapy to help the patient cope with his or her
symptoms, or recommend pharmacotherapy options.
Availability of Treatment. Geographic location limits the availability

of CBT, but not medication, for OCD. Despite increasing numbers of profes-
sionals who are trained to deliver CBT, access to qualified therapists remains
limited, especially in rural areas where there are no academic medical centers
or universities with clinical psychology training programs. Thus, many pa-
tients must travel for adequate treatment. Insurance coverage may also dic-
tate the availability of both CBT and pharmacotherapy, as some insurance
providers do not adequately cover mental health treatment.
Two self-help CBT programs have been developed for OCD. Fritzler,
Hecker, and Losee’s (1997) 12-week bibliotherapy program involved using
Steketee and White’s (1990) self-help book, When Once Is Not Enough, and
five sessions with a therapist to review information presented in the book.
Improvement among the nine patients in this study was modest, yet three
obtained clinically significant benefit. Greist et al. (2002) described an inter-
active and computerized telephone-based self-help behavioral therapy
program called BT Steps. The intervention included education about OCD,
treatment planning, instructions for ERP tasks, and relapse prevention. Pa-
tients who received this program improved about 25% in their OCD symp-
toms, yet whether these gains were maintained in the long term was not
reported. Thus, although some degree of benefit may be obtained from
self-help programs, the lack of therapist contact likely jeopardizes the
integrity of exposure, and may compromise long-term outcome.
Patient Preference. Pharmacotherapy and CBT involve dissimilar ap-

proaches to conceptualization and treatment. Pharmacotherapy is most
consistent with biological theories that implicate the role of neurotransmit-
ter dysregulation, whereas CBT is derived from models that emphasize the
role of conditioning, avoidance, and cognitive biases in the maintenance of
OCD. The chief practical considerations associated with each treatment
were described previously. Research in our clinic suggests that OCD pa-
tients have generally favorable impressions of both treatment approaches,
but strongly prefer CBT to medication as their treatment of choice (Deacon
& Abramowitz, 2005a). Research has not clearly indicated whether it is
most advantageous to match a patient’s treatment to his or her preference,
encourage the patient to accept one modality over another, or combine
treatment methods. Therefore, it is worthwhile for the clinician to review
the advantages and disadvantages of CBT and pharmacotherapy before as-
sessing the patient’s preference because greater adherence can be expected
if the patient is agreeable with the particular treatment modality. For exam-
ple, some individuals are unwilling to endure exposure to feared situations
as would occur in CBT. If this is the case, it is important to ascertain the na-
ture of such concerns so that they may be addressed during the consulta-
tion. An example of how to present treatment options for OCD patients is
provided later in this chapter.
Social Support. Although not a requirement for all patients, the ef-
fects of CBT may be enhanced by the involvement of a support person
who becomes familiar with the treatment procedures and helps the pa-
tient complete therapy exercises outside of the session. This individual
should be capable of providing firm, yet empathic, emotional support
(Mehta, 1990). It is therefore important for the clinician to carefully evalu-
ate family members’ interactions with the patient before assuming that
their assistance with CBT will be beneficial. If family members are
unsupportive, meddling, ridiculing, or argumentative, involving them in
CBT may be counterproductive. For patients who are in need of positive
support, group CBT may be a good option.
When it is clear that family members’ behavior is serving to maintain
OCD symptoms, the clinician should address this issue in a straightfor-
ward yet sensitive manner and educate all parties about its potentially del-
eterious effects on treatment. In some instances the patient and family are
able to align themselves together in addressing the patient’s symptoms. In
others, where family dynamics might undermine the benefits of CBT, fam-
ily therapy or pharmacotherapy is suggested as a first-line treatment. Van
Noppen and Steketee (2003) provide an excellent discussion of family con-
siderations in the treatment of OCD. The following is an excerpt from Susan
T.’s consultation in which the issue of Susan’s husband’s involvement in
OCD symptoms was raised.
Therapist: So, it sounds like Steve sometimes helps you by checking that
the appliances are unplugged before going to bed or leaving
the house. Do you have to ask him to do these things?
Susan: Not so much anymore. He knows I get upset, so he just does
them automatically.
Steve: That’s right. I worry that if Susan got too anxious she might
lose control or go crazy or something. I would just as soon do
whatever I can to keep her from getting upset. It must be bad
for her to be so anxious, so I do these things to help. It’s not
that big of a deal.
Therapist: Sure. I can understand that; you care about Susan and don’t
want her to get too upset. I’d probably want to do the same
thing if I were in your position. Actually, many people with
156 CHAPTER 7
OCD involve their spouses in rituals for the same reasons.

Sometimes, though, we do things that we think are helpful, or
that seem helpful to avoid an immediate problem, but which
may be problematic in the long run. Let me explain so you can
see what I mean.
As I said before, compulsive rituals are ways that Susan
copes with her obsessional fears of being responsible for mis-
takes or causing disastrous consequences such as fires. But
rituals are maladaptive strategies because even though they
make her feel a little better for a short while, they prevent her
from getting over her fear of mistakes or fires. This happens
because if Susan checks, or if you check for her, she never has
the chance to learn to cope with her anxiety or see that her
fears are unlikely to come true. So, Steve, although you mean
well by helping Susan with her rituals, and although it makes
her more comfortable in the short run, the long-term effect is
that it is actually preventing her from overcoming her illogi-
cal fear. Do you see that?
Susan
and Steve: Yes.
Therapist: If Susan decides to begin treatment with me, I will help her
to learn to manage her obsessional fears in more healthy
ways so that she does not need to repeatedly check or wash,
or ask you to do these things. Also, I will teach you how to be
supportive of Susan in a way that will help her become less
dependent on checking. Rather than cooperating with Su-
san’s OCD, you will practice helping her see that compul-
sive rituals are unnecessary and wasteful. Of course, not
doing rituals for Susan anymore probably seems like a diffi-
cult task. Some families worry that this will make the person
with OCD even more upset. This is understandable, and I
will work with you both so that you, Susan, can overcome
your reliance on these rituals.
HOW TO DISCUSS TREATMENT OPTIONS WITH PATIENTS
After considering the patient’s clinical presentation and motivation for

treatment, and the numerous factors described earlier, treatment recom-
mendations are discussed in an open and evidence-based format. Most pa-
tients are aware that medications and psychological treatment are available
for OCD. Less understood is that only certain types of drugs, and certain
forms of therapy, are likely to be helpful. The excerpts presented next are
taken from Susan T.’s initial consultation.
The Effectiveness of Medications
The clinician should rely directly on research results (see chapter 5) when
addressing questions about the effectiveness of treatment.
Therapist: One form of treatment for OCD is medication. The specific

kinds of medication that are known to help OCD are called
serotonin reuptake inhibitors, or SRIs, and a psychiatrist
who is knowledgeable about OCD would prescribe them for
you. Examples of SRIs include Paxil, Prozac, Luvox, Zoloft,
Anafranil, and Celexa. There have been many studies con-
ducted to evaluate the effectiveness of these medicines, and
this research shows that about half of those who take these
drugs for OCD do fairly well. The research also shows that
on the average, symptom relief is between 20% and 40%. So,
for many people, the SRIs are helpful to the point that there
is noticeable improvement in their lives. It is hard to say
which of the SRIs is best for OCD, but most psychiatrists
have their preferences as far as which drug they tend to pre-
scribe. Also, because everyone responds a little differently,
it would be difficult to make a prediction about how helpful
an SRI would be for you. The SRIs are actually antidepres-
sants that have been found to also help with anxiety prob-
lems. And the truth is that we do not understand exactly
how they work to reduce OCD. Some experts think that SRIs
correct serotonin problems. But remember that we are not
certain of the role serotonin plays in OCD.
Advantages and Disadvantages of Medication
Practical considerations weigh heavily in patients’ preference for a treat-

ment. With pharmacotherapy, the main advantages are accessibility and
ease of administration. Disadvantages include the modest improvement
rate, need for long-term use, and side effects.
Therapist: Medication treatment for OCD has some important advan-

tages. Many people like this treatment because it is so conve-
nient. It is easy to obtain from a drug store once it is has been
prescribed, and there are no therapy sessions to go to. If you
were to leave town for an extended period of time, you could
take the medication with you. Usually, your doctor gives you
instructions for how much of the drug to take and when to
take it, and once you swallow the pill, the drug does all of its
158 CHAPTER 7
work internally. At the beginning, you might have to visit the

psychiatrist a few times to establish the best dose for you.
Then, you return for monitoring every few months.
Susan: But if I take medication, do I have to stay on it for the rest of
my life?
Therapist: Well, let’s talk about some of the disadvantages of SRIs. First,
as I mentioned, the average person achieves only modest im-
provement. So, in other words, even with an optimal re-
sponse, most people who take SRIs still have noticeable OCD
symptoms. A second drawback is that to keep up any im-
provement in symptoms, you must continue to take the med-
ication. That is, OCD symptoms typically return if the
medication is stopped; even if you’ve been taking it for a long
time. While some people don’t mind taking medicine, others
prefer not to be on drugs for a long time. The third disadvan-
tage of SRIs is that they can produce unwanted side effects
such as dry mouth, sleep changes, weight gain, and sexual
dysfunction. This is because SRIs act on serotonin function-
ing all over the body, not just in the brain, and serotonin is in-
volved in many bodily functions. In most cases, side effects
can be tolerated, or managed by having the psychiatrist
change the dose of the drug. It is hard to predict the kinds of
side effects you might have because everyone responds to
medication a little differently.
The Effectiveness of CBT
Summarizing the treatment outcome research reviewed in chapter 5 pro-

vides a basis for the effectiveness of CBT and demonstrates to the patient
that the clinician is knowledgeable. Clinicians should also point out how
the assumptions underlying the specific CBT techniques are distinct from
those underlying serotonergic medication. Moreover, it is helpful to link
each treatment procedure to its intended effect (e.g., response prevention
is aimed at reducing compulsive urges). The following discussion, which
occurred during Susan’s consultation, could be adapted for any individ-
ual with OCD.
Therapist: CBT is based on understanding OCD at the symptom level,

rather than on a biological level. As we talked about before,
we understand a great deal about the symptoms of OCD and
how they develop into maladaptive thinking and behavior
patterns. In CBT, you learn skills that weaken these patterns.
For example, you practice techniques that weaken your pat-
tern of becoming very anxious over obsessional thoughts and

situations. You also learn skills to weaken the pattern of using
compulsive rituals to reduce obsessional anxiety. CBT is
highly effective for OCD and we know this from the many
studies that have been conducted around the world on this
treatment. In the research on CBT, most patients typically
show a reduction in obsessions and compulsions of 50% to
70%. So, we would expect you to show a great deal of im-
provement with this treatment.
Four techniques are used in CBT. The first is education,
which means that you learn about your obsessions and com-
pulsions and how CBT is used to reduce these symptoms. An-
other technique is called cognitive therapy, which involves
helping you identify and correct problematic thinking styles
that lead to anxiety. The two most powerful techniques in CBT
are called exposure and response prevention. Exposure means
gradually confronting the situations and thoughts that trigger
obsessional fear, such as public bathrooms or upsetting
thoughts about Jennifer. Response prevention means that you
practice staying in the situation until the anxiety decreases on
its own, rather than escaping by doing rituals. For example,
not washing or checking. Although these techniques are
highly effective, they are also challenging. You have to face sit-
uations that you’ve been working hard to avoid. Although this
is done gradually and with the therapist’s help and encourage-
ment, you would almost certainly become anxious at the be-
ginning of exposure practice. However, by practicing
exposure and response prevention, you would learn that your
anxiety actually lessens the more you remain exposed—even
if you resist doing rituals. This is called habituation. So, expo-
sure therapy helps reduce obsessional anxiety and response
prevention helps you to weaken the habitual pattern of using
rituals to reduce obsessional anxiety.
Advantages and Disadvantages of CBT
Clinicians should emphasize that CBT requires a great deal of work up

front, but this effort is likely to pay off in the long run. It may be helpful to
provide assurance that the therapist will carefully titrate these exercises
so that distress is minimized. The transitory nature of exposure-induced
distress can also be explained using a plot similar to that in Fig. 7.1, which
illustrates the phenomena of within- and between-session anxiety reduc-
tion (habituation).
160 CHAPTER 7
FIG. 7.1. Graphical illustration of anxiety reduction within and between ex-
posure therapy sessions. This graph can be used to illustrate for patients con-
sidering CBT the transient nature of distress that is likely to accompany sys-
tematic exposure to fear-evoking cues during treatment. The dashed line de-
picts the immediate reduction in anxiety that occurs if a safety-seeking ritual
is performed. Rituals prevent the reduction in obsessional anxiety that would
occur naturally over time if no rituals were performed. It is important for pa-
tients to experience the natural habituation of anxiety to reduce obsessional
fear.
Therapist: The greatest advantage of CBT is that it is the most effective

treatment for OCD. Of course, I cannot guarantee you suc-
cess, but it is certainly likely that CBT will lead to appreciable
levels of improvement for you. Another advantage is that
CBT is brief. Typically, improvement occurs within about 15
to 20 sessions. Third, the effects of CBT are long lasting. So,
once therapy is over you will have learned skills that no one
can take away from you. In other words, you will become
your own therapist and be able to apply these skills as neces-
sary in your life. So, CBT is a brief treatment that is more effec-
tive than medication in the short term and in the long run.
However, there are also some disadvantages to CBT. First,
as you have probably noticed, CBT requires a great deal of
work. You will have to come to regular treatment sessions
and practice confronting situations that you have been trying
to avoid—situations that will most likely make you anxious.
You will also be practicing exposure exercises outside the of-
fice between sessions. For example, based on what you told

me, you would probably practice touching surfaces such as
bathroom doorknobs, toilets, and the like, which might make
you worry about germs. Of course, you would receive help
with these tasks and there will never be any surprises. Nor
will anyone force you into doing exposures. What I mean is
that you would play a big role in deciding on when you do ex-
posure to different situations.
As I said, you will almost definitely feel uncomfortable dur-
ing exposure exercises, but you should know that your thera-
pist will work with you to minimize your distress. For
example, you would start slowly and begin with exposure to
less distressing situations, gradually working your way up to
more challenging ones. Also, your anxiety will subside as time
goes by. So, each time you repeat exposure to these situations
you will experience less and less distress. That is how expo-
sure therapy works. It is hard to say how much discomfort you
might have during exposure because it varies from person to
person. However, I can tell you that the anxiety will be tempo-
rary, and that with practice you will see that it decreases.
So, as you might have guessed, how much improvement
you get out of CBT is related to how much effort you put into
doing the therapy exercises. You must decide to invest the
time and energy in CBT to gain control over your OCD symp-
toms. You have to choose to become anxious to learn that you
really have very little to fear. CBT can be exhausting, but the
reward for your hard work up front is that you are likely to
see improvement that will last over the long term. This is dif-
ferent from medication where there is less of an effort in-
volved, yet the improvement is not likely to be as substantial.
Combining Medication With CBT
The effectiveness of combination treatments for OCD is discussed in chap-

ter 5. Despite the intuitive appeal of combining two effective treatments,
concurrent medication use is not necessary for patients to gain substantial
benefits from CBT. An exception to this would include patients with severe
co-occurring depression and perhaps those with very poor insight into the
senselessness of their OCD symptoms.
Therapist: Patients and their families often ask whether a combination

approach—using CBT and medication together—produces
a better outcome than either treatment alone. Unlike what
162 CHAPTER 7
you might expect, the several research studies that have

looked at this question indicate that for most patients, medi-
cation is not required to see substantial benefits with CBT. In
other words, using both treatments is not likely to produce a
better outcome than you would have with CBT alone. But
you should also know that medication does not interfere
with the effects of CBT. So, you do not need to stop your
medicine, especially if you feel it has been helpful. If you
have been on SRI medication and are still having obsessions
and compulsions, the research suggests there is a good
chance that adding CBT will lead to added improvement.
So, I would say that if you begin CBT, you should not start or
stop any OCD medication right before or during psycho-
therapy, because then we would not be able to tell which
treatment was responsible for any beneficial or adverse ef-
fects, in case we had to change the treatment plan.
Making a Recommendation
A review of the procedures, effectiveness, and the pros and cons of each
treatment provides a compelling rationale for recommending CBT in most
cases. Exceptions would be instances in which patients have not responded
to previous adequate trials of CBT, do not have the time to commit to ther-
apy, are otherwise motivated, or are unwilling to tolerate the temporary
evocation of obsessional distress during exposure practices. We find pa-
tients and their families often feel comforted by our knowledge and exper-
tise regarding the various treatment options and appreciate being included
in the decision process. We also let the patient know that although our deci-
sion is guided by expertise, we remain flexible regarding the course and
regimen of treatment depending on how therapy progresses.
Therapist: My recommendation is that you consider beginning CBT be-

cause it is likely to be most helpful and long lasting. It is true
that you will need to work hard and even endure some initial
distress during therapy, but I can tell you that this will be tem-
porary and we will do everything we can to help you succeed.
I believe that if you are willing to invest some anxiety up front,
the chances are good that you will have a more relaxed future.
What thoughts do you have about what I’ve said?
8
Information Gathering
and Case Formulation
The initial phase of CBT involves a detailed assessment of the cognitive-be-

havioral phenomenology and maintenance processes involved in the pa-
tient’s particular obsessional fears and safety-seeking responses. From this
information, the therapist synthesizes an individualized cognitive-behav-
ioral formulation of the problem. It is this formulation that will guide treat-
ment planning and the implementation of therapeutic procedures
described in subsequent chapters. The first part of this chapter presents a
detailed description of how to conduct a cognitive-behavioral (functional)
analysis of OCD symptoms. This includes instructing the patient in
self-monitoring his or her safety-seeking behaviors. In the second part, the
reader will learn how to synthesize information gleaned through func-
tional analysis and derive a case formulation that informs treatment plan-
ning. Susan’s case, introduced in chapter 6, is used throughout this chapter
to illustrate the assessment and case conceptualization procedures.
INFORMATION GATHERING
The initial assessment and diagnostic procedures described in chapter 6 set

the stage for a more comprehensive functional assessment in which idiosyn-
cratic circumstantial, cognitive, and behavioral features of the patient’s
163
164 CHAPTER 8
symptoms are carefully identified, and the links between these features are
understood. Assessment may be considered an exchange of information
between the patient—who enters treatment presumably able to describe
his or her own OCD symptoms—and the clinician—who is able to draw on
a conceptual template of OCD phenomenology to derive a treatment plan
that addresses the patient’s particular symptoms. Therefore, the therapist
must ascertain the specific nuances of the patient’s obsessions and rituals,
and the patient must learn how to understand these symptoms from a cog-
nitive-behavioral (functional) perspective to optimize assessment and
treatment. The composition of a cognitive-behavioral assessment for OCD
is summarized in Table 8.1, and the steps involved in obtaining this infor-
mation are outlined later. Special issues related to assessment of the various
OCD symptom dimensions are also addressed. Forms for recording infor-
mation obtained during this part of the assessment appear in Fig 8.1.
Review of Recent Episodes
To gain additional insight into the patient’s experience and how he or she
copes with symptoms, the clinician can ask for a “play-by-play” descrip-
tion of a few specific instances of obsessional fear, avoidance, and com-
TABLE 8.1
Components of Functional Assessment of OCD Symptoms
Obsessional stimuli
Situations and stimuli that trigger obsessions
Obsessional thoughts, impulses, images, and doubts
Cognitive features
Dysfunctional beliefs and interpretations of obsessional situations and
stimuli (feared consequences)
Catastrophic misinterpretations of intrusive thoughts
Intolerance for uncertainty
Not-just-right experiences
Fears of harm from experiencing long-term anxiety
Safety-seeking (responses to obsessional distress)
Passive avoidance
Compulsive behavior (rituals)
Covert neutralizing strategies
Self-monitoring of obsessional situations and safety behaviors
FIG. 8.1. Forms for conducting a functional assessment of OCD symptoms.
(continued on next page)
165
FIG. 8.1. continued.
166
FIG. 8.1. continued.
167
168 CHAPTER 8
pulsive behavior. This technique could also be used to focus the

assessment on a particular symptom the clinician is having difficulty un-
derstanding. What was the context in which obsessional distress was
evoked? What was the first sign of trouble? Then, the patient is asked to
step through the situation and report his or her emotional and cognitive
responses. What was he or she feeling and thinking? What happened
next? How anxious did he or she become and what was done to reduce
this anxiety (e.g., compulsive rituals, avoidance)? How did the situation
resolve itself and how did the patient feel afterward? The clinician should
be sure to point out for the patient the functional relationships between
obsessions and increased distress, and between safety-seeking rituals or
avoidance and anxiety reduction. For example:
• That’s a great example of how your obsessional doubt about causing a

fire evoked a high degree of anxiety. Then, when you drove all the
way back home to check and you saw that the toaster was unplugged,
you said that you felt relieved. Do you see how your checking rituals
reduce your anxiety?
• It sounds like when you have one of these unacceptable thoughts about
the devil, it makes you feel uneasy and afraid, but then you pray to God
and tell him you’re devoted to him and it makes you feel relieved.
Identifying Obsessional Stimuli
Next, the therapist begins collecting specific information on the full range
of OCD symptoms. It is important that assessment is thorough so that treat-
ment can address all situations and thoughts that present problems for the
patient. Information gathered using the Y–BOCS symptom checklist can be
used to guide the assessment.
Assessing Situational Triggers
Specific information about the range of situations and objects that evoke
the patient’s obsessional fears should be identified first. The most straight-
forward way to identify such triggers is to inquire about situations that are
avoided or that elicit urges to perform rituals. Notably, different situations
and stimuli may elicit the same fundamental fear for different patients. For
example, two individuals concerned with other people’s saliva may have
distinct triggers: One might fear contamination only from people known to
be sick, whereas another may fear all public surfaces because of the possible
presence of saliva. In addition, the same stimulus might be associated with
different fundamental fears for different patients. For example, some indi-
viduals fear pornographic magazines because they may be contaminated
INFORMATION GATHERING AND CASE FORMULATION 169
with body fluids, whereas others fear such material because it evokes unac-
ceptable sexual thoughts and images. Thus, it is important to clarify why a
situation or stimulus evokes fear.
Contamination. The most common feared contaminants are bodily

wastes and fluids (e.g., urine, feces, blood, sweat, semen, saliva), garbage
(and garbage receptacles), chemicals (e.g., pesticides), dirt, animals, and
corpses. Many (but not all) patients assume that contamination is easily
spread to nearby surfaces (e.g., urine gets on the floor), thus secondary
and tertiary triggers of contamination obsessions need to be identified.
For example, recall that urine was a primary source of contamination for
Susan. However, her fear extended to secondary sources such as one of
her students who she believed failed to wash his hands after using the
bathroom. As a result, anything this student handled—his assignments,
books, doors, pencils, and even his parents—also triggered obsessional
fear. Some secondary sources have less of a logical connection to the pri-
mary source. For example, patients afraid of contamination from blood
occasionally fear anything that is the color red. Questions such as, “What
things make you feel contaminated or want to wash or clean?” are useful
ways to elicit pertinent information.
Harming. Situations that activate obsessional guilt and anxiety con-

cerning responsibility for harm or mistakes are highly idiosyncratic. Rou-
tine activities such as leaving the house (“What if I left an appliance on and
a fire starts?”) or turning off a light switch (“What if I only imagined turn-
ing it off?”) might be triggers. Other possible cues include driving (for fear
of hitting pedestrians), discarding bags or envelopes (for fear of throwing
away money or important papers, often observed in patients with hoarding
problems), seeing broken glass (which could result in injury if not picked
up), or completing paperwork (fears of errors resulting in negative conse-
quences). Words (e.g., accident, cancer) or numbers (e.g., 13) that the patient
associates with danger, harm, or bad luck may also trigger obsessional fear.
For Susan, grading papers and entering grades into the computer were sig-
nificant sources of distress. She worried about assigning poor grades by
mistake, which might lead to “ruining a student’s life.” She also described
mild to moderate fear evoked by leaving her home—she worried that she
would be responsible for a fire.
Incompleteness. The most common triggers of incompleteness ob-

sessions are a sense of asymmetry, imbalance, or disorderliness. This may
pertain to situations, objects, feelings, or words and numbers; for exam-
ple, having books arranged “out of order” on a bookshelf, having
“messy” handwriting, or finding one’s clothes not folded perfectly. One
170 CHAPTER 8
woman became distressed if she was touched or brushed on one side of

her body but not the other. Simply hearing the word left without hearing
right evoked discomfort for this individual. Another patient became anx-
ious over odd numbers, for example, on the odometer or when balancing
the checkbook. There was no sense of danger, just the idea that odd num-
bers were “wrong.”
Unacceptable Thoughts and Covert Rituals. Intrusive unacceptable

thoughts about violence, sex, and blasphemy are often classically condi-
tioned to external triggers such as knives or baseball bats, horror movies,
Halloween, cemeteries, holding a baby, pornography, information about
homosexuality, specific people, words, numbers, and religious icons. One
patient was afraid of anything having to do with the New Jersey Devils
hockey team for fear of “devil thoughts.” In fact, he avoided everything
regarding the state of New Jersey (e.g., maps, postcards, license plates).
Another feared places of worship because they evoked unwanted blas-
phemous intrusions such as, “Jesus is gay.” Still another patient feared
women’s lingerie stores (e.g., Victoria’s Secret) for fear of seeing attractive
women and experiencing unwanted doubts about her sexual preference.
A more dramatic example is that of a man who feared going to sleep at
night because he once dreamed of having sex with his father and feared
having such a dream again. Susan T.’s unwanted thoughts of harming her
infant daughter were evoked by the sight of knives and by bathing the
baby in the bathtub.
Assessing Obsessional Thoughts
Intrusive, senseless, and unacceptable thoughts, ideas, images, im-

pulses, and doubts that evoke feelings of anxiety, shame, terror, or dis-
gust are hallmarks of OCD and every patient experiences them in one
form or another. Although these are often overlooked in strictly behav-
ioral models and treatment of OCD, cognitive-behavioral models regard
these internal stimuli (often triggered by situational cues) as normal ex-
periences that evoke inappropriate fear and uncertainty because of how
they are appraised. Some patients conceal their obsessions, believing
that to vocalize such thoughts would increase the probability of the cor-
responding negative event. As an example, one man refused to talk
about his unwanted impulse to kiss his male boss because he thought
that verbalizing this idea somehow brought him closer to acting on the
impulse. Other patients conceal because they are ashamed or embar-
rassed by the content and frequency of the obsessional intrusion. On the
one hand, the therapist must understand that describing these noxious
thoughts may be a great challenge for patients. Nevertheless, because
the aim of treatment is to weaken the connection between such thoughts

and anxiety, patients need to be encouraged to disclose the content of
even their most disturbing obsessions.
Patients are often comforted (and surprised) when they see that the ther-
apist is neither alarmed nor disgusted by the content and frequency of the
obsessions. Many individuals seem to scrutinize the therapist’s reactions
for any signs of horror. Responding genuinely, but in a “matter-of-fact”
way, reinforces the notion that even the most bizarre or obscene obsessions
are normal, nonthreatening, and do not necessitate any extraordinary emo-
tional response. This is illustrated in the following dialogue.
Patient: (with trepidation) I know this sounds crazy, but I often think
about “what if I stabbed my wife in her sleep?”
Therapist: Um hmm, sure [nods empathically]. I’ll bet that’s pretty scary
for you.
Patient: Yes, it is. Now, you must think I’m some sort of psychopath.
Therapist: (matter-of-factly) No, not really. Does it look like I’m worried
about you killing your wife in her sleep? [A thorough assess-
ment had been conducted to rule out any history of actual ag-
gressive behavior.]
Patient: Well, no. But all the other therapists I’ve had were shocked and
wanted to try and figure out why I was thinking those things.
Therapist: I see. My approach is much different than theirs, for sure. We
know from lots of scientific research that everyone has those
kinds of thoughts, and that they are not dangerous or signifi-
cant, especially given your history of not being a violent per-
son. So, instead of trying to figure them out, we’re going to
help you realize that those thoughts are not at all threatening
or psychopathic. They’re not worth figuring out. It might
help you to know that I’ve also had these kinds of thoughts.
Contamination. Patients with contamination fears typically report

persistent thoughts, images, and doubts regarding germs and illness at-
tributable to contact with feared contaminants. Some entertain obsessions
about being responsible for contaminating others and thereby causing
them harm. Rachman (1994) described a phenomenon known as mental
pollution, which is a more or less obscure sense of internal “dirtiness” sel-
dom traceable to a specific source, but which may be induced by circum-
stances such as memories of traumatic events, unwanted unacceptable
thoughts (e.g., images of molesting children), or humiliation. Susan re-
ported some of the most common contamination obsessions: images of
germs on her hands, thoughts of being sick, and doubts about whether she
really was contaminated.
172 CHAPTER 8
Harming. Persistent doubts are the chief obsessional thoughts for this
symptom presentation. The individual might question whether he or she
has accidentally injured or killed someone (e.g., while driving) or did
enough to prevent catastrophes. Doubts about mistakes, negligence, or
mishaps, such as inserting inappropriate or hurtful language into conver-
sations or e-mail messages, are also common. Individuals with scrupulos-
ity entertain nagging doubts about largely unanswerable questions of
whether they have acted morally or followed religious doctrines to the let-
ter of the law. Susan had doubts about whether she had assigned grades
correctly or recorded them accurately on students’ report cards. Perhaps
she would be responsible for a promising student not being accepted to a
private school or college. Doubts about whether she might cause (or had
caused) a house fire were also present. Lastly, Susan had obsessional
thoughts about not doing enough to keep her husband and children from
becoming very sick or dying because of feared contaminants. This last ex-
ample illustrates an overlap between the contamination and harming
symptom dimensions.
Incompleteness. Specific obsessions may be difficult to identify within

this symptom presentation. Most patients report the sense that something
is “not just right,” or images of themselves “going crazy” or “out of control”
due to experiencing prolonged anxiety or distress.
Unacceptable Thoughts and Covert Rituals. This dimension of OCD

represents the purest example of obsessional thoughts, impulses, and im-
ages that evoke discomfort. Violent or aggressive obsessions include un-
wanted ideas such as “I could burn my child with the iron,” the thought of
pushing one’s wife onto the tracks when the train is approaching, or “what
if I yell racial slurs at my friend who is an ethnic minority?” Sexual obses-
sions can take several forms, including unwanted ideas of molesting or
raping others, thoughts or images of consensual yet personally undesirable
sexual behavior (e.g., incest, homosexuality), unwelcome thoughts of im-
proper sexual activity (e.g., with someone other than your spouse), and un-
acceptable images such as that of one’s grandparents having sex. Religious
obsessions may include blasphemous images (e.g., of Jesus with an erection
on the cross) or other thoughts and doubts that create the feeling of having
sinned (e.g., unwanted thoughts questioning the existence of God). Susan
experienced unwanted thoughts of violence against her infant, Jennifer.
The most distressing thoughts were those of losing control and stabbing
Jennifer, and of drowning her in the bathtub. It is interesting to note that vir-
tually any thought has the potential to become an obsession if its presence
or meaning is appraised as threatening or significant in a negative way.
Next, we turn to the appraisal component of obsessions.
Identifying Dysfunctional Beliefs

and Interpretations of Obsessional Stimuli
As I described in Part I, the cognitive-behavioral model of OCD distin-

guishes between obsessional stimuli and the meaning that patients give to
these stimuli. The model proposes that obsessional fear results from dys-
functional appraisals, interpretations, and perceptions of situations and
stimuli that objectively pose a low risk of harm. Because CBT aims to mod-
ify these dysfunctional beliefs, the therapist must be aware of such thinking
patterns. Figure 8.1 includes space for recording patients’ feared conse-
quences of exposure to obsessional situations and thoughts.
Examples of questions to elicit dysfunctional cognitions include the
following:
• What is so bad for you about using public bathrooms? What bad
things do you expect to happen?
• What do you tell yourself before leaving the house that makes you
feel like you need to check all the appliances?
• Why is it so bad for you to have thoughts about sex while you are in church?
• What might happen if you are holding a knife and you think about
stabbing your child?
• What are you afraid would happen if you touched your shoes and
didn’t wash your hands?
The downward-arrow technique (Burns, 1980) is a useful way of identi-

fying specific dysfunctional beliefs (overestimates of severity, likelihood,
and the need to prevent harm) about obsessional situations and thoughts.
This method involves asking the patient to describe an episode of obses-
sions and compulsions, followed by probe questions to identify the funda-
mental or core beliefs that evoke fear, avoidance, or neutralization (e.g., “If
that were so, what would be the worst thing that could happen?”).
Susan described an episode in which she avoided shaking hands with
people in a reception line at her church. The following transcript illustrates
the use of the downward-arrow method to identify Susan’s feared conse-
quences of contact with other people.
Therapist: Can you tell me what you were worried about when you
were going through the reception line?
Susan: I was afraid that people’s hands were sweaty. It was very hot in
the church that day and I didn’t want to get other people’s sweat
on me. I felt like I had to wash my hands as soon as possible.
Therapist: I see. What would have happened if you shook their hands and
touched their sweat without washing your hands afterward?
174 CHAPTER 8
Susan: There would be other people’s germs on me.

Therapist: OK. And what would happen next?
Susan: I would probably get sick, or spread the germs to my kids and
make them sick.
Therapist: And what do you imagine that would be like? How sick
would everyone become?
Susan: Well, it could depend. Probably just a cold, but perhaps worse.
Therapist: How much worse?
Susan: I don’t know … salmonella poisoning, bacterial infections?
Someone could get really sick.
Therapist: How likely is it that you would get sick from shaking hands
with someone at your church and not washing your hands?
What percent?
Susan: Maybe 70 or 80 percent.
Therapist: So it sounds like that reception line was scary for you because
you were telling yourself that shaking people’s hands, with-
out washing your own, would probably result in you and
your family becoming very sick.
Susan: Yes, that’s right.
As the reader can identify, Susan’s beliefs included overestimates of the

probability, severity, and responsibility for preventing illness. Note that at
this point the therapist does not question or challenge the patient’s clearly
unrealistic assumptions. Instead, the focus is on developing rapport and
collecting information about the cognitive basis of obsessional fear.
Not all patients articulate the kinds of explicit fears of disastrous conse-
quences just illustrated. Some report that obsessional cues evoke only a
vague sense that “something bad will happen,” and others say they would
“just feel anxious.” The downward-arrow method often reveals that the un-
derlying catastrophic beliefs for such individuals are that their anxiety or
distress will persist indefinitely, spiral to unmanageable levels, or lead to
harmful consequences (e.g., “I will have a breakdown”). Research suggests
that it is important to help patients clarify their feared consequences, even if
they are merely that anxiety will persist indefinitely, so that such fears can
be explicitly disconfirmed during exposure exercises (Foa et al., 1999).
Self-report questionnaires should be used to assist with ascertaining dys-
functional beliefs. Two excellent instruments developed by the OCCWG
(2001, 2003, in press)—the Obsessive Beliefs Questionnaire (OBQ) and Inter-
pretation of Intrusions Inventory (III)—assess many of the OCD-related cog-
nitive distortions discussed in chapter 3. These two measures are reprinted in
Appendix F. Other questionnaires, as described next, have been devised to
identify cognitions associated with specific OCD symptom dimensions.
Contamination. The cognitive basis of contamination symptoms is

the belief that feared contaminants pose a significant threat to one’s physi-
cal or mental well-being, or pose a significant social threat. Moreover, pa-
tients may believe they are especially vulnerable to harmful effects of
contaminants, and that unsafe levels of contamination are easily transmit-
ted to oneself or to others (Rachman & Hodgson, 1980). Many, but not all,
individuals with contamination symptoms overestimate the probability
and severity of becoming ill or spreading illnesses to others (Jones & Men-
zies, 1997a, 1997b). Other patients describe disgust (Tolin, Woods, &
Abramowitz, in press) or imperfection associated with their contamination
concerns and fear that the associated distress will persist indefinitely or in-
crease to harmful levels if action is not taken to remove feared contaminants
and restore a “perfect state of cleanliness.” The responsibility–threat esti-
mation subscale of the OBQ measures the tendency to overestimate the
probability and severity of danger as well as responsibility for spreading
illness to others. The Disgust Scale (Haidt, McCauley, & Rozin, 1994) as-
sesses sensitivity to disgust-evoking stimuli.
Harming. Intolerance of uncertainty regarding feared situations plays

a role in nearly all OCD symptom dimensions, but is most prominent in ob-
sessional thoughts and doubts about harm and mistakes. That is, people
with this symptom presentation often fear that because harm could occur
(no matter how slim the possibility), they must act to prevent it or face full
responsibility for its cause (e.g., “I can’t take the chance that the feared out-
come will occur”). The probability and severity of feared negative out-
comes are also overestimated. Sometimes, fear is associated with
uncertainty regarding negative consequences that might occur in the dis-
tant future, or that can never be confirmed or disconfirmed (e.g., getting
cancer in old age, going to hell when one dies). Several self-report measures
can be used to assess the catastrophic cognitions associated with the harm-
ing dimension. The Responsibility Attitudes Questionnaire, which mea-
sures general beliefs about responsibility, and the Responsibility
Interpretations Questionnaire, which measures specific interpretations of
intrusive thoughts about harm, are extremely useful and can be found in an
article by Salkovskis et al. (2000). For patients with scrupulous doubts, the
Penn Inventory of Scrupulosity (reprinted in Abramowitz, Huppert, et al.,
2002) assesses the fear of committing sins and catastrophic beliefs about di-
vine punishment.
Incompleteness. Obsessions involving the need for symmetry and or-

der are often mediated by the need to have things perfect, balanced, or com-
pletely under control, or by what more recently have been termed not just
176 CHAPTER 8
right experiences (NJREs; Coles, Frost, Heimberg, & Rheaume, 2003). Some
patients fear that the sense of uneasiness over having things incomplete
will persist indefinitely or increase to unmanageable levels and result in
psychological harm. Coles, Frost, Heimberg, and Rheaume (2003) devel-
oped the NJRE questionnaire, which assesses the presence of such experi-
ences (e.g., “When hanging a picture on the wall I have had the sensation
that it did not look just right”). For a minority of patients, responsibility
cognitions and intolerance of uncertainty mediate incompleteness symp-
toms. Such individuals associate NJREs with an increased chance that di-
sastrous consequences (e.g., bad luck, accidents, death) will befall
themselves or their loved ones.
Unacceptable Thoughts and Covert Rituals. Intrusive blasphemous,

violent, or sexual ideas, images, and impulses are often catastrophically ap-
praised as personally significant and indicators of immorality, depravity,
perversion, evil, dangerousness, or insanity. Cognitive distortions include
“only cruel, maleficent people think about hurting loved ones,” “If I think
about what my grandparents look like naked, it means I am a depraved,
perverted, ‘freak,’” and “My blasphemous thoughts mean that I am an ut-
ter disgrace to God.” Patients might also believe that their violent thoughts,
if not kept in check, will lead to action: “Because I think about stabbing my
wife in her sleep, I am likely to do it,” or “If I don’t control my sexual
thoughts, I will become a rapist.” The Importance/Control of Thoughts
subscale of the OBQ, and the Thought–Action Fusion Scale (Shafran et al.,
1996), are excellent self-report instruments for assessing the belief that
thoughts are psychologically equivalent to the corresponding actions
(moral TAF), and that thoughts about negative events increase the likeli-
hood of such events and should therefore be controlled (likelihood TAF).
Identifying Responses to Obsessional Stimuli (Safety Behaviors)

Next, the focus shifts to assessing the deliberate responses that patients per-
form to reduce obsessional discomfort, or evade it altogether; namely
avoidance, compulsive rituals, and other neutralizing strategies. These
safety-seeking behaviors arise from the catastrophic beliefs and percep-
tions described in the preceding section. For example, avoidance of public
bathrooms is motivated by the fear of illnesses. Urges to check the roadside
for dead bodies are motivated by intolerance of uncertainty regarding cul-
pability for hit-and-run accidents. Mental rituals to neutralize violent ob-
sessions are motivated by the belief that violent thoughts are equivalent to
violent behavior and must be controlled (i.e., TAF). As these examples illus-
trate, the patterns of thinking and behavior in OCD are meaningful and in-
ternally consistent to the patient (after all, who wouldn’t try to dismiss
thoughts of violence if they believed such thoughts lead to violent actions).
Thus, from within the context of the patient’s thinking, the therapist can of-
ten anticipate what safety-seeking behavior is used in a given situation (a
rhetorical move that may increase the patient’s confidence).
Therapist: When you park the car, do you always have to make sure the
odometer ends in an even number?
Patient: Yeah. How did you know?
Therapist: Well, you said that you’re afraid odd numbers will lead to
bad luck. So, it makes sense that you would avoid them. Lots
of people with OCD do this.
Patient: But I waste so much time doing that. I mean, it’s not really
logical, is it?
Therapist: That’s what OCD is all about. It has its own logic that it tricks
you into following.
Patient: Wow. I feel like you really understand my problem. I really
think you’re going to be able to help me.
Avoidance, rituals, and other neutralizing strategies are targeted in

treatment not only because they are wasteful and interfere with daily func-
tioning, but because they prevent extinction and hinder the correction of
catastrophic beliefs (see chapter 4). Clinicians should inquire about how the
patient interprets the outcome of his or her avoidance and safety-seeking
maneuvers. Often, the lack of a disastrous outcome is perceived as a near
miss, implying that safety seeking prevented the harm (e.g., “I would have
become ill if I hadn’t washed my hands,” or “If I didn’t stop on an even
number, something bad would have happened”). Accordingly, to reduce
obsessional fear, all of these responses must be eliminated in CBT (i.e.,
response prevention).
The initial consultation should yield information about the patient’s main
rituals and areas of avoidance. However, it is unusual for individuals to
spontaneously describe their full array of safety-seeking behaviors during
the initial assessment. Some avoidance, mental rituals, and neutralizing
strategies might be so subtle or routine that they are not recognized as part of
OCD. To facilitate reporting of these covert and surreptitious responses, the
therapist should introduce the concepts of avoidance and safety seeking as
protective responses to obsessional fear. Patients should be given examples
of these strategies and encouraged throughout assessment and treatment to
report any behaviors or mental strategies performed with the intent of allevi-
ating obsessional distress. To this end, good assessment questions include
the following:
178 CHAPTER 8
• What else do you do when confronted with situations and thoughts

that evoke obsessive fears?
• When you’re feeling anxious about (fill in obsessional fear), how do
you reduce your distress?
Passive Avoidance
Passive avoidance, which is defined as the intentional failure to en-

gage in an objectively low-risk activity, can often be predicted from ob-
sessional cues and catastrophic beliefs. For example, fears of corpses
might lead to avoidance of funerals; fears of thoughts about molesting
children might lead to staying away from playgrounds; fear of AIDS of-
ten leads to avoidance of anything red (which might be blood); fears of
bad luck may result in avoidance of the number 13; and so on. Some pa-
tients ask others to engage in avoidance, such as in the case of a man who
forbid his wife to shop in a certain “contaminated” food store. Good
questions for patients include the following:
• What kinds of things do you not do because of your obsessional fears?

• Do you ask other people to avoid certain situations for you?
The clinician should feel free to ask about additional avoidance strate-
gies if there is good reason to think they might be present; for example:
• I know you are afraid of touching the floor. Do you also avoid touch-
ing shoes because of this?
Contamination. Common examples include avoidance of shoes,

floors, unknown substances of particular colors (e.g., red spots), and particu-
lar surfaces (railings, door handles), people, and animals. This may include
touching the “least used” part of the door handle, using a sleeve or tissue to
push the elevator button, or squatting above the toilet seat. In more severe
cases avoidance extends to secondary and tertiary (and so on) sources, leav-
ing the patient with few “safe” or “clean” areas in which to function freely.
One example is a man who feared being poisoned by lawn chemicals such as
fertilizer. During spring he could not leave his home, and moreover, he wor-
ried that items brought into his house might contain traces of harmful lawn
chemicals that were in the air. The patient had also established “safety zones”
in his home where contaminated items (and people) from outside were not
allowed unless they had been thoroughly washed (or had recently show-
ered). All other “contaminated” parts of the home were avoided.
Harming. Avoidance in this symptom presentation might involve
situations and activities in which the person perceives that he or she could
be responsible for causing or preventing for harm, or which evoke

thoughts of feared consequences. The clinician should use knowledge of
situational triggers and obsessional thoughts to guide assessment. Typi-
cal examples include driving, using the oven, writing bank checks, read-
ing articles about disasters or illnesses, and being in charge of locking up
the house (e.g., the last person to go to bed or to leave the house). Some
avoidance is more subtle, such as not driving near school buses for fear of
hitting children. One patient avoided listening to music or watching tele-
vision while she wrote or typed on the computer because she was afraid
that the distraction would lead to mistakenly writing obscenities. An-
other tried to avoid exposure to all obscene words or gestures for fear that
he might use them at inappropriate times.
Incompleteness. The purpose of avoidance in the incompleteness di-

mension is often to reduce the need for rituals. Patients may avoid certain
rooms knowing that entering them would evoke urges to rearrange objects,
create “balance,” or perform counting rituals. If perfectionism is the prob-
lem, one might avoid buying new items to prevent having to continually
work on their upkeep. In a particularly severe case, a patient isolated him-
self as much as possible because of his persistent urges to mentally count
letters in words, and words in sentences that he read or heard.
Unacceptable Thoughts and Covert Rituals. Patients with unaccept-

able, repugnant thoughts, images, or impulses often do what they can to
avoid stimuli that trigger such thoughts. They may also avoid situations in
which they fear acting on unwanted impulses. For violent or aggressive ob-
sessions this includes potential weapons (knives, guns, baseball bats) and
victims (babies, the elderly); police; words associated with violence (blood,
murder); and places, pictures, shows or movies, or news articles associated
with harm or violence. Depending on content, avoidance related to sexual
thoughts might include hetero- or homoerotic material, gay bars, sexually
provocative people (of either sex), gym locker rooms, changing diapers, no-
ticing people’s crotch or breasts, shows about pedophiles or rapists, or
words like rape or bestiality. People with blasphemous obsessions may
avoid places of worship for fear of committing blasphemy there, or reli-
gious objects for fear of offending God. Words such as hell, devil, Satan, or
curse words may also be avoided.
Because of her contamination fears, Susan T. avoided touching most sur-
faces that other people often touch, including handrails, door handles, pub-
lic telephones, and other people’s writing implements. Public restrooms
were a particular problem, as were gym locker rooms because of the sweat.
This presented problems at school, where Susan suspected that a number of
her students did not adequately wash themselves after using the bathroom
180 CHAPTER 8
or after their physical education class. Thus, items belonging to these chil-
dren (and their close friends) were also avoided. In addition, Susan some-
times avoided holding or bathing her daughter, Jennifer, because of the fear
of acting on intrusive violent thoughts.
Rituals
Most patients exhibit multiple types of rituals. Some of these could be

described as compulsive—highly repetitive or performed according to
strict rules (e.g., turning the light on and off 15 times), whereas others are
brief and less rule-bound (e.g., using a “good image” to cancel a “bad im-
age”). The clinician should obtain information about the frequency and du-
ration of each ritual. Is the same ritual used each time a particular obsession
arises? How does the patient know when it is safe to stop the ritual? Clini-
cians should also ask for a complete description of each ritual, including a
demonstration (when practical) if the verbal description is unclear. Some
rituals may be embarrassing to describe, such as excessive wiping after us-
ing the toilet. If this appears to be the case, the therapist should inquire in an
understanding yet straightforward way; for example, “Many people with
fears of bodily waste take a lot of time using the bathroom because they
have to make sure they are entirely clean. Is that a problem for you? Would
you feel comfortable describing what you do?”
Clinicians should also assess the functional relationship between rituals
and obsessional fear. Recall that in general, rituals are deliberate attempts
to escape from anxiety or prevent feared consequences. Inquiry might in-
clude questions such as these:
• How do you feel after you have checked?

• When you finish washing your hands, how do you feel about the risk
of getting sick or making other people sick?
• How do you think canceling out the blasphemous thoughts affects
your moral standing?
Contamination. Susan T.’s decontamination rituals were typical of

patients with this symptom presentation: excessive hand washing, shower-
ing, and toilet routines; cleaning inanimate objects such as the shower stall,
toilet, clothes, or items brought into the home; and using barriers when
touching contaminated objects (this may be considered avoidance or ritual-
istic). Like many patients, Susan had a specific routine for washing herself
in the shower and this included counting the number of times she washed
various body parts. Some patients involve others in decontamination ritu-
als, such as one woman who had her husband and children change their
clothes when they entered the home. As mentioned previously, along with
specifics of each ritual (time spent, frequency), it is important to assess stop-

ping rules; that is, how does the patient know when he or she can stop
washing or cleaning?
Harming. Checking is the chief method of relieving anxiety and un-

certainty regarding obsessions of responsibility for causing or preventing
harm. Susan often rechecked the grades she assigned to students for fear
that she had made errors. Before leaving the house and going to bed, she
repeatedly checked that appliances were off to prevent fires. Clinicians
should clarify the frequency and duration of checking rituals; Susan’s
routine often took up to 30 minutes and she had to repeat these rituals if
any intrusive doubts about mistakes occurred during this routine. Other
common examples include checking that other people have not been hurt
(e.g., looking for bodies on the roadside, watching the news for stories of
hit-and-run accidents), checking for egregious oversights (e.g., “Did I put
poison in the baby’s food?” “Did I write ‘f—- you’ instead of ‘thank
you’?”), checking to prevent loss (e.g., of one’s wallet), checking that one
has been understood by others, and repeatedly asking others for reassur-
ance or clarification. The involvement of others in checking rituals should
be assessed. Susan, like many patients, often asked her husband to re-
check that appliances were safely off. Other patients repeatedly telephone
loved ones to make sure they are safe—thus the other person is involved
by simply answering the phone.
Some individuals use repeating or ordering rituals to reduce doubts
about responsibility for harm. For example, one man had to put his
clothes on the “right way,” otherwise he feared his parents would die in a
car accident. Often he would dress and undress multiple times because he
did not feel the ritual had been done properly. Unlike with checking, the
link between repeating rituals and fears of disasters is not readily appar-
ent and may seem magical. Other examples include having to tap a certain
number of times or go through doorways the “correct” way to prevent
some sort of harmful idea that comes to mind. In some instances, the num-
ber of times the ritual can (or cannot) be performed is determined by lucky
or unlucky numbers (e.g., even numbers, multiples of 5). Thus, assess-
ment should also include questions about the details of counting and
numbers with special significance.
Incompleteness. In this symptom dimension, compulsions are per-

formed primarily to achieve order, achieve perfection, and reduce NJREs;
they might not be limited to manipulating objects. For example, one patient
who heard or read the word left felt a strong urge to hear or read the word
right (and vice versa). Other examples include the need to mentally count
letters in words (or words in sentences), to look or stare at certain points in
182 CHAPTER 8
space to establish symmetry, and the urge to rewrite things until they look
balanced or perfect.
Unacceptable Thoughts and Covert Rituals. Identifying covert ritu-

als requires careful inquiry because these phenomena are often subtle and
may occur exclusively in the patient’s mind. When Susan’s violent obses-
sional thoughts of harming her daughter evoked anxiety, she resorted to
“canceling out” these thoughts with another thought. Specifically, she re-
peated the following prayer to herself seven times: “Please God, I pray to
thee, don’t let me harm my daughter.” It bears emphasizing here that clini-
cians must avoid labeling mental rituals as obsessions simply because they
are cognitive events. Recall that whereas obsessions are involuntary
thoughts that evoke distress, mental compulsions (like their behavioral
counterparts) involve purposeful thinking (i.e., mental behavior) that is in-
tended to reduce distress.
Mental rituals can be assessed straightforwardly by asking questions such
as, “Sometimes people with OCD use mental strategies in response to their
recurring unwanted distressing thoughts. Do you ever use any strategies like
that?” Providing examples may elicit additional information: “A common
mental ritual is to ‘cancel out’ obsessions by repeating special ‘safe’ words,
phrases, or images to yourself. Do you ever do this?” Some patients mentally
review their behavior or analyze particular events over and over to reassure
themselves of the invalidity of intrusive thoughts (e.g., trying to reason
through whether or not one’s intrusive doubts really mean they do not be-
lieve in God). A variation is testing, wherein the person tries to collect some
sort of evidence that feared consequences are improbable. For example, one
man with intrusive doubts about the nature of his sexuality (he feared he was
homosexual) repeatedly looked at other men’s buttocks and focused atten-
tion on his internal state to determine whether he felt sexually aroused.
Patients with unacceptable thoughts may use overt rituals as well, such
as checking for harm or asking for assurance. We have even observed pa-
tients who wash their unacceptable thoughts away as if feeling contami-
nated by them. This highlights the importance of assessing the
idiosyncratic cognitive links between obsessions and rituals. Here, useful
questions include the following:
• What else do you do when these unwanted thoughts come to mind?

• Why does doing that ritual make you feel better?
Covert Neutralizing
Most neutralization attempts are brief and unobservable; this inaccessi-

bility makes them a challenge for many clinicians to recognize. Because
neutralization is functionally similar to compulsive rituals—both produce

short-term anxiety reduction yet reinforce obsessional beliefs in the long
term—it must be a target of therapy. Freeston, Ladouceur, Provencher, and
Blais (1995) have developed an interview to assess a variety of neutraliza-
tion strategies used with obsessional thoughts, which is reprinted in Ap-
pendix G. The interview allows the clinician to obtain data on the context in
which specific neutralizing strategies are used, as well as on the perceived
effectiveness of each strategy.
Susan reported two of the most common neutralizing strategies:
thought suppression and concealment. She attempted to suppress intru-
sive thoughts about harming her infant whenever they came to mind. Her
reasons for suppression attempts included concern that she might act on
the thought if it remained in her mind, and that she felt like a terrible
mother for thinking such thoughts. In general, Susan said that her sup-
pression attempts did not work well. Moreover, she reported feeling that
her failure to dismiss “bad” thoughts meant she really was becoming a vi-
olent person. Susan concealed her obsessional thoughts about harm and
mistakes from others because she was concerned that others would think
she was a bad mother or an incompetent teacher if they knew the kinds of
thoughts she had. She was also concerned that she was the only person
who thought this way, and believed that verbalizing these thoughts might
somehow bring her closer to acting on them (i.e., “If I talk about it, I am
one step closer to doing it”).
SELF-MONITORING OF SAFETY BEHAVIORS
Once information gathering is initiated, the patient is introduced to

self-monitoring. Asking patients to keep a log of their symptoms is a stan-
dard procedure in virtually all forms of CBT. In the treatment of OCD,
self-monitoring involves recording instances of obsessional fear, avoid-
ance, and safety behaviors as they occur in real time. It is an important tool
because it furnishes the patient and clinician with precise information
about the situational cues, frequency, intensity, and duration of these symp-
toms. For patients with multiple symptom dimensions, one or two particu-
larly prominent symptom themes can be chosen for self-monitoring. A
model form for self-monitoring appears in Fig. 8.2. Clinicians can review
the form with patients by having them record actual recent examples. Be-
cause it can be an arduous task, some patients have difficulty with adher-
ence to self-monitoring. It is therefore essential to acknowledge that the
exercise requires substantial effort. Nevertheless, it is an important compo-
nent of treatment. A cogent rationale for self-monitoring should be pre-
sented that underscores the need for accurate and timely recording of
symptoms. Patients should be instructed to keep the form with them at all
184
FIG. 8.2. Example of a self-monitoring form.
times, rather than waiting until the end of the day (or immediately before
the next session) to try to recall all instances of safety behaviors. Susan T.’s
therapist gave the following explanation:
Therapist: I realize that doing self-monitoring might seem demanding.

After all, you probably have never done this kind of exercise
before. Let me give you three reasons why self-monitoring is
an important part of treatment. First, it will give us accurate
information about the problems you are having with OCD in
your daily routine. In other words, it will tell us about the var-
ious triggers and thoughts that evoke compulsive rituals and
how much time these problems take up. Second, it will help
us assess your improvement. In other words, toward the end
of therapy we can look back and examine how much less you
are ritualizing. Finally, self-monitoring can actually help you
reduce your OCD symptoms right away. That is, many peo-
ple say that just knowing they have to write it down helps
them resist doing rituals. So, I want you to do an honest job
and I will be looking forward to seeing your completed forms
at the beginning of the next session. In fact, the first thing we
will do next time will be to review your forms.
When examining the completed self-monitoring form, the clinician

should stop to ask the patient to review a few exemplary episodes in
greater detail. Critical information for the clinician to acquire includes
how obsessional fear is triggered (e.g., “What is it about driving that wor-
ries you?”), what situations are avoided (e.g., “Do you always avoid driv-
ing near school buses?”), and why (“What do you think might happen if
you drove behind a school bus?”). Also, how does the patient respond to
obsessional fear (“What else, besides checking, do you do to reduce your
fears of molesting a child?”). Self-monitoring aids the clarification of in-
ternally consistent associations among the patient’s fear, avoidance, and
rituals. These associations should be clear to the therapist; if they are not,
further examples should be reviewed until they are clarified. Situations
and thoughts that trigger rituals should be considered for inclusion as ex-
posure exercises (see chapter 10).
CASE FORMULATION
At the end of the functional assessment, the therapist should have the infor-
mation necessary to construct an individualized model of the patient’s spe-
cific OCD symptoms. This case formulation incorporates the content of
obsessions, appraisals, and safety behaviors, as well as the processes that
186 CHAPTER 8
maintain these symptoms. The formulation must be credible to the patient

and provide a rationale for using CBT procedures such as exposure, response
prevention, and cognitive therapy to reverse the maintenance processes.
Constructing an Individualized Formulation
The case formulation is synthesized from information collected during the

functional assessment. A straightforward approach is to begin by listing (a)
the situations and thoughts that trigger obsessional fear, (b) the associated
dysfunctional and catastrophic misinterpretations, and (c) safety-seeking
behaviors. Next, based on the cognitive-behavioral model of OCD (see
chapters 3 and 4), derive links between these content-related phenomena
with arrows to indicate the influence of maintenance processes on the
symptoms and cognitions. It is smart to involve the patient in developing
the formulation to impart a collaborative ownership of the model. Sketch-
ing the model for the patient to see (e.g., on a whiteboard) and inviting his
or her input conveys that conceptualization and treatment planning are
open processes (as opposed to secretive). This is likely to foster buy-in to the
model and the recommended treatment strategies.
A case formulation of Susan’s main OCD symptoms appears in Fig. 8.3.
Stimuli such as bathrooms and certain “dirty” students from her class trig-
gered obsessional thoughts of contamination. Obsessional doubts about
mistakes were evoked when grading students’ papers and entering these
grades into the computer. The sight of knives, other sharp objects, and situ-
ations such as giving Jennifer a bath precipitated intrusive violent ideas of
harming this child. Susan reported perceiving trigger situations as overly
dangerous and risky. On measures of OCD-related cognitive distortions
(e.g., the III and OBQ), she endorsed the tendency to misinterpret the pres-
ence and meaning of her intrusive thoughts and impulses as overly signifi-
cant and needing to be controlled. She also evidenced overestimates of
threat, an inflated sense of responsibility for causing and preventing harm,
and an intolerance of uncertainty.
For some patients it is possible to draw hypotheses about the origins of
dysfunctional cognitions, although this is not a required element of the case
formulation. The cognitive-behavioral model suggests that the ways in
which Susan perceived obsessional situations and thoughts might have
been influenced by early experiences that produced relatively stable beliefs
about her self and the world (including her thoughts). For example, Susan
said that when she was a child her mother had repeatedly warned her
against wishing bad things on people because such wishes might come
true. Perhaps such experiences fostered strong beliefs (i.e., core beliefs) that
merely thinking about something could influence the outside world, or that
thoughts about harmful circumstances are equivalent to the corresponding
FIG. 8.3. Case formulation for Susan T.’s OCD symptoms.
187
188 CHAPTER 8
events. This would explain, for example, why Susan feels highly responsi-
ble for preventing harmful consequences that she merely thinks about.
Although some patients might seem to gain fulfillment by speculating
about the possible origins of their OCD symptoms, discussions of this na-
ture should be kept to a minimum because such speculations can never be
verified and contribute little in CBT. Moreover, the effectiveness of CBT
techniques depends not on an awareness of causal factors, but instead, on
an understanding of the processes that lead to the persistence of such
symptoms. Another trap to avoid is that of speculating about what may
have influenced the content of obsessional thoughts themselves; for ex-
ample, whether traumatic childhood experiences, such as sexual abuse,
led to obsessions about certain topics (e.g., sexual obsessions). Recall that
cognitive-behavioral models assume that how one appraises and re-
sponds to obsessional thoughts is more important than the content of the
intrusions themselves.
Assessment revealed a number of factors that contributed to the persis-
tence of Susan’s obsessional fears. First, safety-seeking responses to obses-
sional distress, such as avoidance, rituals, and other neutralizing behavior
(e.g., concealment), prevented her anxiogenic beliefs and misperceptions
from self-correcting. For example, Susan credited her compulsive hand
washing, rather than a low probability of harm, with preventing her from
becoming ill when exposed to feared contaminants. Similarly, she believed
that her failure to stab her daughter was due to her ritualistic prayer and
avoidance, rather than to the fact that she is a gentle person with good judg-
ment. Because these safety behavior responses resulted in immediate
(albeit temporary) anxiety reduction, their use was reinforced.
According to the cognitive-behavioral theory, Susan’s anxious mood
and attempts to suppress unwanted thoughts also contributed to the per-
sistence of obsessions. As part of her body’s normal anxiety response (i.e.,
the flight-or-flight response) she became hypervigilant and preoccupied
with triggers and obsessional thoughts. Thought suppression habits led to
a paradoxical increase in unwanted thoughts, which, in the context of be-
liefs about the necessity of controlling such thoughts, was misperceived as
further evidence of danger (e.g., “When I try to dismiss the thoughts, they
come back—there must really be something terribly wrong”).
Deriving a Treatment Plan Based on the Formulation
Developing a patient-specific case formulation is important because it clar-

ifies the targets of CBT and specifies an internally consistent relationship
between the symptoms and treatment. Susan’s case formulation, which is
prototypical of individuals with OCD, suggests that effective treatment

must accomplish a number of goals. First, Susan must be taught to under-
stand her symptoms according to the formulation. If she accepts this con-
ceptual model, it is likely that she will work with the therapist to more fully
engage in office-based and homework treatment procedures. Second, Su-
san must be trained to distinguish between intrusive obsessional thoughts
and the appraisals or interpretations of these stimuli. Third, Susan must
learn to challenge the catastrophic beliefs and interpretations of obses-
sional stimuli that lead to anxiety, and develop more realistic and healthier
ways of thinking. Fourth, avoidance and other maladaptive habitual re-
sponses to obsessional fear (i.e., compulsive rituals and neutralization)
must be replaced with healthier responses that promote the correction of
dysfunctional catastrophic thinking and the extinction of obsessional fear.
The implementation of treatment procedures that are used to achieve these
goals is described in the next several chapters.
9
Cognitive Therapy:
Education and Encouragement
The first cognitive theorist, in a manner of speaking, was the Roman

(Greek-born) slave and Stoic philosopher Epictetus (55–135 AD). He is
credited with introducing the idea that although we do not always have
control over the positive and negative circumstances and events that occur
in our lives, we can control how we think about these situations. Further-
more, he proposed that negative emotional states such as depression and
anxiety are caused not by situations themselves, but instead by overly neg-
ative or exaggerated (maladaptive) interpretations of situations. The impli-
cation here is that we can gain mastery over our emotions by learning to
interpret events and situations—even negative ones—in adaptive (al-
though not necessarily positive) ways. However, what to Epictetus and the
Stoics was self-evident—and what has been demonstrated again and again
by scientific study (e.g., Frost & Steketee, 2002)—is often overlooked by in-
dividuals with OCD who may seek to blame their troubles on things such
as genetics, abnormal brain chemistry, bad parenting, and traumatic expe-
riences. The reason for this oversight is obvious—interpretations are tran-
sient, nebulous, and not readily observable. They occur rapidly and with
such subtlety that many people hardly notice them at all. Although it may
be difficult for patients to see that the faint voice they hear in their heads is
190
COGNITIVE THERAPY: EDUCATION AND ENCOURAGEMENT 191
the real culprit, overcoming OCD ultimately requires changing how one in-
terprets key internal (mental) and environmental stimuli.
Cognitive therapy (CT) techniques for OCD are concerned with the
identification and correction of dysfunctional beliefs about obsessional
stimuli that, according to the cognitive-behavioral model, lead to obses-
sional fear and maladaptive responses such as avoidance and safety behav-
iors. CT is educational. To a degree it assumes that if the patient knew the
truth about the low probability of harm associated with obsessional stim-
uli, he or she would not have obsessional problems. Fear-evoking stimuli
would be perceived as nonthreatening and safety-seeking behavior would
be unnecessary—it would indeed be redundant.
What is the role of CT in CBT? As I reviewed in chapter 5, research indi-
cates that cognitive techniques by themselves have limited efficacy in re-
ducing OCD symptoms. The most powerful treatment procedures for
reducing OCD are exposure and response prevention. However, this does
not mean that CT elements do not contribute to treatment outcome. Indeed,
cognitive techniques can play a substantial role in facilitating assessment,
preventing premature discontinuation, and maximizing adherence with
difficult ERP exercises (Kozak & Coles, 2005; Salkovskis & Warwick, 1985;
Vogel et al., 2004). In particular, CT can help weaken dysfunctional cata-
strophic beliefs and appraisals to the point that the patient can more easily
engage in and profit from exposure exercises. Additionally, CT helps with
the development of a trusting therapeutic relationship, the importance of
which is often underestimated in exposure therapy. Thus, clinicians should
view the cognitive techniques described in this chapter as setting the table
for therapeutic exposure.
This chapter begins with a description of general stylistic issues to be
considered when using cognitive interventions. Next, several practical CT
techniques for facilitating belief change and engagement in ERP are de-
scribed. The chapter concludes with discussions about when it is appropri-
ate to use these techniques.
STYLISTIC CONSIDERATIONS
Two general styles of CT are used in the treatment of OCD: didactic presen-
tation of psychoeducational material and Socratic dialogue regarding mis-
taken beliefs. Often the therapist switches back and forth between the two
styles as both are verbal methods and can easily be incorporated into dis-
cussion. I mentioned earlier that CT is educational; indeed, most patients
hold an incomplete understanding of the intricacies of their OCD symp-
toms. They do not realize that intrusive senseless thoughts are normal, uni-
versal experiences; that beliefs cause anxiety; and that safety behaviors
192 CHAPTER 9
used to deal with obsessional anxiety are counterproductive. Patients un-

dergoing CBT must be taught to view their problem according to this model
because it is the conceptual basis of treatment. If the patient is not socialized
to this model properly, he or she may reluctantly go along with some ele-
ments of therapy, but refuse to sufficiently engage in the more challenging
components such as ERP. Helping patients to think about their own OCD
symptoms along the lines of the cognitive-behavioral model also helps so-
lidify a collaborative therapeutic relationship (i.e., the patient and therapist
are working together as a team).
Psychoeducation
During the initial therapy sessions, psychoeducation should focus on the

following points:
• Intrusive thoughts are normal experiences.

• Catastrophic thinking leads to obsessional anxiety and compulsive
(neutralizing) behavior.
• Avoidance, compulsive rituals, and neutralizing strengthen obses-
sional fears
• Correcting faulty thinking and appraisals, and dropping safety-seek-
ing behaviors, will lead to a reduction in obsessional fear.
The presentation of psychoeducational material should be preceded by a

discussion of the patient’s preexisting understanding of his or her problem.
This allows the new information to be used to correct particular inaccura-
cies, rather than acting as general reassurance.
The Socratic Style
The Socratic style employs open-ended questions, reflective listening, and

summary statements that are all aimed to help the patient gain greater per-
spective on his or her dysfunctional beliefs and to foster the consideration
of suitable alternatives. As Wells (1997) has pointed out, appropriate open
ended questions include those that:
• Open up a particular area of exploration (e.g., “What is it like for you

when you have to use the bathroom?”).
• Clarify a point of view (e.g., “When you say you ‘think you will get
sick,’ what particular illnesses do you have in mind?”)
• Probe for worst case scenarios (e.g., “What’s the worst thing you im-
age happening if you don’t wash your hands after using the bath-
room?”).
In reflective listening, the therapist reflects what the patient has said
with a slight degree of reframing or modification for the sake of clarifying
the patient’s point of view. This also communicates the therapist’s respect
for the patient and the therapeutic relationship, and can be used to selec-
tively reinforce ideas that the patient expresses (Taylor & Asmundson,
2004). For example:
Patient: After I use the bathroom I spend 10 minutes washing my

hands to make sure all the germs are washed away.
Therapist: So, after urinating, you feel you have to wash your hands to
prevent illness.
and
Patient: If I think that maybe I hit someone with my car, I have to drive
back and check the road to be sure nothing happened.
Therapist: So, the way you are responding when you have intrusive
doubts is by checking—as if the doubts were really true.
Summary statements further facilitate reflection on the dialogue and in-

corporate a follow-up question:
• So, you avoid public bathrooms because you are afraid of catching
diseases from toilet seats. I wonder how you think people who don’t
avoid public bathrooms feel about toilet seats?
• Have you ever actually hit someone with your car? Do you think you
would know if it actually happened? What might that be like?
It is important for the therapist to demonstrate curiosity and a genuine

interest in learning how the patient experiences his or her world. The pa-
tient should never feel interrogated or put in the position of wanting to de-
fend his or her erroneous beliefs.
Individuals with OCD, particularly those with insight into the sense-
lessness of their symptoms, are often ambivalent about their obsessional
fears and compulsive urges. Although at times they are fearful of cata-
strophic consequences, they would also like to believe that such outcomes
are improbable. The fact that most patients at one time or another have
successfully resisted the urge to ritualize suggests that they have thought
about the senselessness of their fears and necessity of safety behaviors
(e.g., “Maybe I don’t need to change my clothes every time after I use the
bathroom”). It is helpful for the therapist to amplify the patient’s ambiva-
lence and elicit a sense of cognitive dissonance because this will foster
open-mindedness and willingness to test (and change) dysfunctional be-
194 CHAPTER 9
liefs. Importantly, instead of forcefully telling the patient that he or she is

wrong about the probability of disastrous consequences or the meaning of
obsessional thoughts, the therapist should carefully help the patient draw
his or her own conclusions and generate more reasonable alternative be-
liefs based on any available evidence. Forcefully trying to convince the
patient that he or she is wrong can backfire and cause the patient to defend
his or her illogical position.
There is widespread agreement among cognitive-behavioral therapists
concerning the importance of using Socratic methods whenever possible.
Studies from the fields of clinical and social psychology demonstrate that
people hold onto beliefs more strongly when the beliefs are self-generated
as opposed to when they are spoon-fed to them didactically. Thus, al-
though didactic psychoeducational procedures have their place in treat-
ment, supplementary discussions of didactic material should be
conducted by using Socratic questioning to lead the patient to the desir-
able conclusions. The examples in Table 9.1 illustrate the differences be-
tween a didactic style and a Socratic style.
NORMALIZING OBSESSIONAL THOUGHTS
As I have alluded to in previous chapters, numerous studies (e.g.,

Rachman & de Silva, 1978) show that intrusive thoughts are normal expe-
riences: Over 90% of the general public reports them. In OCD, however,
the presence and content of these thoughts is misinterpreted as significant
and threatening. Patients often incorrectly feel they are mad, bad, or dan-
gerous for having such thoughts. Therefore, time should be taken to de-
scribe the results from research on intrusive thoughts and present
examples of “normal” intrusions. Therapists can review with patients
Handout 9.1, which includes a list of intrusive thoughts reported by peo-
ple without OCD. Patients who conceal their repugnant aggressive, sex-
ual, or religious obsessions should be encouraged to discuss these
thoughts without restraint in recognition that these are normal experi-
ences. It may be helpful for the therapist to model this behavior by openly
sharing some of his or her own intrusive thoughts.
Most patients are at once surprised and relieved to learn that everybody
has intrusive thoughts. Many report that this gives them some reassurance
that they are not “going crazy” or suffering from a chemical imbalance of
the brain. Although the occasional patient rejects this explanation, most be-
gin to challenge the dysfunctional ways they have been interpreting their
obsessions and readily adopt a less threatening view. For those who are less
eager to embrace this account, the therapist can show research articles doc-
umenting the frequency of normal intrusions (in Rachman & deSilva’s
[1978] article in the journal Behaviour Research and Therapy, similarities be-
TABLE 9.1
Examples of Didactic and Socratic Styles
of Conveying Therapeutic Information
Example 1: Obsessional thoughts are normal phenomena.

Didactic style
• Everyone has intrusive, upsetting, unwanted thoughts. In fact, people
without OCD experience the same kinds of unwanted thoughts as do
people with OCD. This is important because it means that people with
OCD are not “abnormal”; their thoughts are no different than people
without OCD. The difference is that people with OCD interpret un-
wanted upsetting thoughts as very significant.
Socratic style
• Are you abnormal because you have unwanted thoughts?
• Are unwanted thoughts always dangerous?
• Can you think of any upsetting thoughts you have had that did not
cause problems for you?
• What do you tell yourself about the intrusive thoughts that might make
them seem threatening?
Example 2: Doing safety behaviors prevents one from learning that his or her
obsessional fears are irrational.
Didactic style
• When you unplug appliances, such as the toaster, and check that they
remain unplugged, it prevents you from learning that your fears of
starting fires are unrealistic.
Socratic style
• When you see that the appliances are unplugged, what do you think af-
terward?
• What does checking make you think about the fact that your house has
not burned down?
• Do you attribute the fact that there has not been a fire to your keeping
the toaster unplugged, or to the possibility that your thoughts about
fires are not necessarily realistic?
tween normal and abnormal obsessions are spelled out with exceptional
clarity). Another strategy is to suggest that the patient take a poll by asking
10 acquaintances whether they sometimes experience intrusive or
upsetting thoughts.
One question that often arises from this discussion is, “Why do people
have strange negative unwanted thoughts in the first place?” To address
this issue it may be useful to explain that the human brain is highly devel-
Unwanted Thoughts
Intrusive thoughts are entirely normal experiences. We know this because
virtually everyone, whether or not they have OCD, has these kinds of
thoughts from time to time. Below are examples of intrusions reported by
people without OCD.
Thought of jumping from a high place like a building

Thought of receiving the news that my husband has been killed
Image of the baby being thrown down stairs
Thought of having a terrible disease like cancer or AIDS
Thought of jumping in front of a fast-moving car
Impulse to jump on the train tracks as a train comes into station
Idea of attacking an elderly person that I love
Thought of leaving the cat in the fridge
Impulse to run over a pedestrian who walks too slow
Thought of harming someone who does not deserve it
Thought of wishing that a person would die
Thought that the baby will die in his crib
Image of taking a wine bottle and threatening someone in the family
Imagining what it would be like if my brother died
Thought of decapitating the baby with a butcher knife
Thought of catching diseases from various people or places
Thought of deliberately crashing the car into a tree or telephone pole
Thought of dropping the baby
Thought of putting the baby in the microwave
Thought that my hands are contaminated after using the bathroom
Thoughts that run contrary to my moral or religious beliefs
Thought of swearing rudely at someone I am not angry with
Idea that I could contaminate or poison my child’s food
Thoughts of smashing a table full of crafts (at a market for e.g.) made of glass
Image of screaming harshly at my baby
Impulse to call my girlfriend and break up even though we are deeply in love
Thoughts of doing something embarrassing such as forgetting to wear a shirt
Thought to yell curse words loudly in a religious service
Thought that I left door unlocked
Thought that I left an appliance on and caused a fire
Thought about objects not arranged just right
Thought of my house getting broken into while I’m not home
Image of what someone’s penis looks like
Image of my grandparents having sex
Sexual thought about someone other than my spouse
Thought of “unnatural” sexual acts
Impulse to inappropriately accost an obese person
Note: Compiled from Abramowitz et al. (2003); Rachman & deSilva (1978);
and numerous personal communications with people who do not have
OCD. Thanks to Sabine Wilhelm, PhD.
Handout 9.1. List of intrusive thoughts collected from nonpatients.

196
oped and capable of enormous creativity. Therefore we are able to imagine

all kinds of scenarios—some pleasant, others unpleasant. Think of how of-
ten we daydream of winning the lottery or scoring the winning touchdown
in the Super Bowl. Just as our “thought generator” produces positive
thoughts that are unlikely to come true, it can also spawn senseless and un-
pleasant thoughts. A related point to be underscored is that the aim of ther-
apy is not to eliminate obsessional thoughts altogether, but rather to reduce
the amount of distress associated with these normally occurring experi-
ences. Once intrusive thoughts are no longer perceived as threatening, it
will not matter when or how frequently they occur.
Normalizing intrusive thoughts is useful for individuals with any symp-
tom dimension, although its most straightforward application is in the case
of unacceptable aggressive, blasphemous, and sexual obsessions, and with
intrusive doubts about making terrible mistakes and being held responsible
for harm. For patients with contamination symptoms this exercise can be
used to normalize images of germs (e.g., the feeling of doubt over whether
one has microscopic organisms on his or her hands or face). One patient in
our clinic, for example, reported recurrent images and ideas about his favor-
ite possessions covered in germs. He considered these thoughts senseless
and bizarre and was concerned there was something wrong with him for re-
peatedly thinking about such things. Senseless thoughts and ideas concern-
ing order, symmetry, and exactness, such as the preference for even numbers
or left–right balance, can also be normalized in this way.
Patients may allude to the fact that although everyone has intrusive
thoughts, their own intrusions are more frequent, more distressing, and
more intense compared to those of nonsufferers. Indeed this is true, and it is
therefore important for patients to understand how normal, innocent intru-
sive thoughts escalate into severe recurrent obsessional preoccupations.
Methods for presenting this information are described next.
PRESENTING THE COGNITIVE MODEL OF EMOTION

Beliefs Create Anxiety
The idea that emotional and behavioral responses are determined by one’s be-
liefs and perceptions about situations and events should be revisited through-
out treatment. This is the A-B-C model, wherein A is an activating event (or
antecedent), B is a set of beliefs about A, and C is the emotional or behavioral con-
sequence of B. It is the causal relationship between catastrophic thinking and
strong emotional responses such as anxiety (the B–C connection) that must be
clearly understood to provide an explanation for how obsessional anxiety
arises. In short, the patient must recognize that the real problem is his or her
dysfunctional beliefs about obsessional triggers and intrusive thoughts, not
the (objectively safe) triggers and intrusions themselves.
198 CHAPTER 9
Dysfunctional thinking may occur on two levels: automatic thoughts

and dysfunctional assumptions. Automatic thoughts are in-situation inter-
pretations and appraisals that go through a person’s mind and provoke an
emotional response. For example, when Susan T. approached a doorknob
she would think, “What if someone with sweaty hands just touched this
door? I will get sick.” Dysfunctional assumptions, on the other hand, are gen-
eral underlying (core) beliefs that people hold about themselves and the
world that make them inclined to interpret specific situations and stimuli in
a catastrophic manner. For example, the beliefs “I am highly susceptible to
illnesses” and “public surfaces contain lots of dangerous germs” would
make someone like Susan fearful if he or she had to touch surfaces that are
often touched by others. As another example, the dysfunctional assump-
tion “thinking about violence can lead to violence” led Susan to interpret
her intrusive thoughts about hurting her infant as threatening and needing
to be controlled (e.g., “I can’t let myself think about this. I might kill Jennifer
if I don’t stop these thoughts.”). Unlike automatic thoughts, dysfunctional
assumptions usually do not enter a person’s consciousness while he or she
is in the anxiety-evoking situation. Instead, dysfunctional assumptions are
best elicited through detailed assessment (as described in chapter 8).
Susan T.’s therapist introduced the A-B-C model and helped Susan un-
derstand how her beliefs and interpretations dictate her emotional and be-
havioral responses as follows:
Therapist: When something happens, we don’t usually take the time to

consider how much our beliefs and thoughts influence our
emotional and behavioral reactions. For example, if I get ner-
vous when I have to take a test, I might tell myself that “tests
make me nervous.” But actually, if I feel nervous over taking
a test it is not really because of the test itself. The test can’t
make me nervous—it’s a piece of paper. The reason I become
nervous is that I am telling myself something threatening
about the test—something like “I’ll probably fail.” So, I actu-
ally make myself nervous over tests. Do you see that?
Susan: Yes.
Therapist: Let’s take another example of how our thoughts and beliefs
influence our emotions. Suppose you and a friend have
planned to meet for dinner at 7:00, but it is now 7:30 and your
friend still hasn’t shown up. If you guess that your good
friend may have been injured in a terrible accident on her
way to meet you, how will you feel?
Susan: Worried.
Therapist: Right. And you might even want to call the police. How will
you feel if you told yourself that she probably found someone
more fun to have dinner with instead of you?
Susan: Sad or depressed, probably.

Therapist: Right again. How about if you believed your friend was be-
ing late on purpose just to jerk your chain?
Susan: Then I’d feel angry.
Therapist: Sure, and with good reason. So, what if instead of thinking
those things, you thought to yourself that your friend is prob-
ably on her way and has some good reason for running be-
hind that she’ll tell you about when she arrives? What would
you feel then?
Susan: I’d probably just feel normal—maybe a little hungry.
Therapist: Right. Do you see the importance of your interpretations?
Susan: Yeah. The situation is the same—my friend is late. But I could
interpret it in different ways; and depending on how I inter-
pret the situation, I will feel differently.
Therapist: That’s exactly right. So, since the only thing that has changed
is your interpretation of the situation, we can say that your in-
terpretations cause your emotional responses. Your beliefs
dictate how you feel.
After demonstrating the cognitive model with a situation that is not

emotionally charged, the next step is to apply it to OCD-relevant situations.
Therapist: Now, let’s see how this might apply to situations and thoughts
that give you problems as part of OCD. You said that you be-
come very anxious and feel like washing your hands for sev-
eral minutes whenever you shake hands with someone. How
must you be interpreting shaking hands that causes you to feel
so anxious and like you have to do the washing ritual?
Susan: I’m telling myself that there are millions of germs on the per-
son’s hands and that they will make me sick if I don’t wash.
Therapist: Exactly. So, your interpretation of what happens when you
shake hands causes both anxiety and urges to do compulsive
behaviors. How about your husband, Steve; does he worry
about shaking people’s hands?
Susan: No. And I don’t understand why it doesn’t bother him.
Therapist: Well, let’s apply the cognitive model. What do you think he’s
telling himself about shaking hands that allows him not to
feel so anxious?
Susan: Maybe that it’s no big deal or that there aren’t enough germs
to hurt you. That’s what he tells me when I worry about it.
Therapist: OK. So, do you see how it is your interpretation of the other
people’s hands as very dangerous that leads you to feel very
anxious about shaking them? If you changed your thinking
and considered that other people’s hands might not be so
200 CHAPTER 9
dangerous, you could probably get yourself to feel more like

the way Steve does.
Susan: I understand, but I can’t just change my mind about the
germs. I think there really is some danger.
Therapist: Right, and that’s what therapy is going to help you with. We’re
going to work together to help you learn how to interpret these
kinds of situations, and your obsessional thoughts, in ways
that will be more helpful to you. For now, though, it is impor-
tant that you see how your thinking affects your anxiety.
In OCD, the anxiety-evoking stimuli (the As in the A-B-C model) are

sometimes intrusive thoughts. Because we typically think of As as external
events or situations (e.g., a toilet, completing a form, the number 13, shak-
ing hands), applying the cognitive model in the case of intrusive thoughts
can be a bit tricky. That is, when both are cognitive events, some people
have difficulty distinguishing between the intrusive obsessional thoughts
(the As) and the automatic thoughts or appraisals of the intrusions (the Bs).
Table 9.2 provides some examples from patients seen in our clinic. Susan’s
therapist helped Susan recognize this distinction and apply the cognitive
model to her obsessional thoughts as follows:
Therapist: The same relationship occurs with your unwanted thoughts

about harm, like the ones about hurting your baby. You said
that when these kinds of thoughts come to mind you start to
believe that you are a terrible mother and that you need to stop
thinking this way. Can you see how you are interpreting your
unwanted thoughts as very significant and even dangerous?
Susan: Yes, I see that.
Therapist: First you have the unwanted intrusive thought about harm
but then you interpret it as meaning that you are a bad person
or that you might act violently. How do you think that makes
you feel? What does it make you do?
Susan: It makes me scared of those thoughts so I avoid the baby or
try to get the thought out of my mind.
Therapist: That’s right. So, the question is, are you correct in believing
that your unwanted gruesome thoughts about harming your
baby really mean you are a bad mother? Do you really need to
avoid or suppress the thought in order not to do something
terrible? Think back to what we discussed about those kinds
of intrusive thoughts.
Susan: Well, if most people have strange thoughts as you said, even
thoughts about hurting people they love, I guess there’s noth-
ing wrong with having the thoughts. But that seems so
strange. I’ve been afraid of those thoughts for so long.
TABLE 9.2
Examples of Intrusive Thoughts, Dysfunctional Automatic Thoughts, and Consequences From Patients With OCDs
Intrusive Obsessional Thought Dysfunctional Automatic Thoughts Consequences

• (In the gym locker room) Unwanted • The thought means I am turning • Thought suppression, seeks reassur-
homosexual image gay. ance of heterosexuality, avoids looking
at other men
• (In the synagogue) Thoughts of • I am an immoral person, I will be • Thought suppression, ritualistic pray-
desecrating the Torah punished. ing for forgiveness, avoidance of the
synagogue
• (Walking in the hospital) Impulse • If I don’t stop this thought, I will • Thought suppression, puts hands in
to push an unsuspecting elderly act on it. pockets, avoids elderly persons
woman to the ground
• (After sealing an important letter • I will be terribly embarrassed. I’ve • Opens the envelope and ritualistically
in its envelope) Doubts that I wrote got to make sure I didn’t write checks the letter
curse words in the letter anything inappropriate.
• Images of germs • If I’m thinking about them, they • Avoidance, hand washing
must be there. I can’t take the
chance that I’ll get sick.
201
202 CHAPTER 9
Therapist: That’s because you have believed for a long time that those
thoughts are important or dangerous. You’ve even been acting
as if they are. But as you just explained to me, they’re really not.
In fact, most new parents have them from time to time. So, lucky
for you, the real problem is not that you have these thoughts,
but rather how you misinterpret them as very significant and
threatening. You can’t change the fact that we all have upsetting
thoughts, but you can change how you interpret these thoughts.
In therapy, you will learn more healthy ways to think about
these thoughts so that (like people without OCD) you can expe-
rience them without becoming alarmed.
Discussing and Challenging Cognitive Distortions
According to the cognitive theory each emotion is linked to a particular type of

thinking. For example, thoughts about the likelihood of danger or harm lead
to anxiety and thoughts of personal loss lead to depression. As reviewed in
chapter 3, OCD is associated with systemtic aerrors in reasoning about respon-
sibility for causing (and preventing) harm, the importance of intrusive
thoughts, the need to control thoughts, the overestimation of threat, need for
perfection, and intolerance for uncertainty among others (Frost & Steketee,
2002). Acquainting patients with the various types of thinking errors helps
them become aware of when they are victims of such patterns. To this end,
Handout 9.2 provides a list of cognitive errors in OCD. The handout, which
can be reviewed in the session, can lead to a discussion of how various cogni-
tive distortions play a role in the patient’s particular OCD symptoms. Inter-
view data collected during the information- gathering sessions and responses
to the self-report measures of cognition administered during assessment (see
chapter 8) may also be used to point out the patient’s distinctive patterns of re-
sponding to obsessional triggers. Important points to convey to patients re-
garding each type of cognitive distortion are discussed next.
Intolerance of Uncertainty. At some level, most avoidance and com-

pulsive behavior in OCD can be conceptualized as attempts to gain reassur-
ance. Consider the woman who wears three layers of clothing fearing that
mosquitoes carrying the West Nile virus will penetrate the first two layers,
the man who locks his kitchen drawers and hides the key so that he does not
stab his children with knives, the woman who rereads her letters (opening
sealed envelopes again and again) to be completely certain she did not
write anything obscene by mistake, the man who avoids looking at another
man’s rear end for fear of having homosexual thoughts and “turning gay,”
and the woman who keeps a journal of all her activities through the day so
that she can reassure herself that she has not had an extramarital affair
Cognitive Distortions in Obsessive-Compulsive Disorder
1. Intolerance of Uncertainty: You feel as if you must have a 100%
guarantee of safety or absolute certainty. Any hint of doubt, ambiguity, or
the possibility of negative outcome (however small) is unacceptable. This
is the core distortion of OCD.
2. Overestimation of Threat: You exaggerate the probability that a negative
outcome will occur; or you exaggerate the seriousness of any negative
consequences.
3. Overestimation of Responsibility: You believe that because you think
about harmful consequences, you are therefore responsible for
preventing harm from coming to yourself or others. Failure to prevent (or
failure to try to prevent) harm is the same thing as causing harm.
4. Significance of Thoughts: You believe that your negative obsessional
thoughts are overly important or very meaningful. For example, the idea
that there is something seriously wrong with your brain because you
have senseless thoughts.
Moral Thought-Action Fusion: You believe that your unwanted
thoughts are morally equivalent to performing a terrible action.
Therefore, you think you are an awful, immoral, or disgraceful
person for thinking these thoughts.
Likelihood Thought-Action Fusion: You believe that thinking
certain thoughts increases the chance that something terrible will
happen. For example, “If I think about death, someone will die.”
5. Need to Control Thoughts: Beliefs about the significance of thoughts
lead you to feel the need to control your obsessional thoughts (and
actions). You worry that if you don’t control (or try to control) unwanted
thoughts, something terrible could happen that you could have
prevented. Some people worry they will act on their unwanted thoughts
unless the thoughts are suppressed.
6. Intolerance of Anxiety: You feel that anxiety or discomfort will persist
forever unless you do something to escape. Sometimes the fear is that
the anxiety or emotional discomfort will spiral out of control or lead to
“going crazy,” losing control, or other harmful consequences.
7. The “Just Right” Error (Perfectionism): You feel that things must be
“just right” or perfect in order to be comfortable. A related belief is the
feeling that things need to be “evened out” or symmetrical or else you
will always feel uncomfortable.
8. Emotional reasoning: You assume that danger is present based simply
on the fact that you are feeling anxious.
Handout 9.2. List of common cognitive distortions in OCD.
203
204 CHAPTER 9
without realizing it. It is as if patients believe the absence of a complete

guarantee of safety is evidence for a high risk of harm. Contrast this way of
thinking with that of most non-OCD sufferers who are able to assume that a
situation is safe simply by the absence of clear-cut danger cues. That is, peo-
ple without OCD have the ability to feel certain about many things despite
the fact that absolute certainty is more or less an illusion. At first it might ap-
pear as if people with OCD have a deficit in their ability to manage uncer-
tainty or ambiguity. However, a closer look shows that they only have
trouble with uncertainty in specific situations that are relevant to their ob-
sessional fears. Susan T.’s therapist used the following demonstration to il-
lustrate for Susan how she already knows how to live with uncertainty:
Therapist: Your husband, Steve. Is he alive right now at this very mo-
ment?
Susan: Sure. Why do you ask?
Therapist: Well, I am interested in how you know for sure that he’s alive.
Susan: I talked with him on my cell phone while I was in the waiting
room waiting for you.
Therapist: How long ago was that?
Susan: About half an hour ago.
Therapist: So you know he was alive then. But isn’t it possible that some-
thing terrible could have happened to him just in the last
half-hour? You never know what could happen, do you?
Susan: I guess that’s true. So, I guess I don’t know for certain that he’s
alive. But, I would bet that he is.
The therapist and Susan next discussed how it would be impossible for
Susan to be certain that Steve is alive at this very moment (indeed meteors,
accidents, and medical emergencies are possible). However, despite this,
Susan coped in a healthy way, basing her judgment on a probability as op-
posed to a guarantee, and not making frantic attempts to check on Steve.
This led to a further discussion about other low-probability events that the
patient takes for granted on a regular basis such as when using scissors (a
potential source of injury), electrical appliances (a potential source of
shock), and crossing the street. Such a discussion can help teach patients
that they already know how to manage uncertainties, and therefore can
learn how to tolerate other low-risk uncertainties, such as those featured in
obsessions. Indeed, to reduce obsessional fear and compulsive urges, pa-
tients must be willing to learn to live with acceptable levels of uncertainty.
Some patients describe obsessional fears of disastrous outcomes that will
occur at some point in the distant future, such as getting cancer from long-term
exposure to pesticides or eternal damnation because of the failure to control
blasphemous or other immoral thoughts. They may be presently avoiding cer-
tain situations or performing compulsive rituals because they believe such
precautions will guarantee that the feared disasters do not ever occur. It is of no
use trying to convince the patient that these feared consequences will never
happen—it is impossible for anyone to know such things. Moreover, such a
strategy would merely be playing out the patient’s ritualistic and maladaptive
ways of coping with this normal uncertainty. Instead, the therapeutic discus-
sion should focus on reaching a shared understanding of the way that OCD
works (i.e., the cognitive-behavioral model) and a less threatening alternative
interpretation of the ambiguity and uncertainty. The aim is to help the patient
discover that he or she already accepts many uncertainties, and therefore can
learn to become more comfortable with others. For example:
Therapist: So, you don’t know for sure whether Steve is alive, but you’d
bet that he is. What kind of a bet are you making when you
have intrusive doubts that maybe you assigned a student the
wrong grade on their report card?
Susan: I’m betting that I made a mistake.
Therapist: Right; and where does that bet lead you?
Susan: I see what you mean. I get anxious and have to check and re-
check. I even called a student’s parents once just to be sure.
Therapist: And how often do you find that you’ve actually made such a
mistake?
Susan: Never. I have never caught any mistakes when computing or
assigning grades on report cards. But it could happen.
Therapist: You’re right. It could. But, remember, Steve could be dead right
now and you could be hit by a car the next time you cross the
street. If you apply the same strategy you use in these cases,
what could you tell yourself about assigning the wrong grade
the next time you have the obsessional doubts?
Susan: I could tell myself that I probably haven’t made the mistakes I
am worried about, that I’m only thinking about it.
Therapist: Exactly. You have to be willing to live with some uncertainty.
That means no longer trying to be 100% sure about your ob-
sessional fears.
Once the patient accepts that he or she must learn to tolerate uncertainty,
ERP exercises can be discussed as vehicles for promoting this change. By
engaging in ERP, the patient will learn that uncertainty is manageable and
that the negative outcomes he or she is concerned with are unlikely to mate-
rialize even if no safety-seeking behavior is performed.
Overestimation of Threat. People with OCD tend to exaggerate the

threat associated with obsessional situations. They predict that their worst
fears will likely come to pass, even when the risk of negative outcomes is re-
alistically quite low. Such predictions can take two forms: overestimation of
206 CHAPTER 9
the probability of harm (jumping to conclusions) and overestimation of se-

verity (catastrophizing). These cognitive distortions fuel anxiety because
they imply that danger is lurking. They also place the patient on high alert
and put him or her at further risk of misinterpreting harmless situations or
events as dangerous.
Socratic dialogue is the recommended format for discussing overesti-
mates of threat. Recall that the aim of such discussions is not to provide a
guarantee of safety, but to help the patient devise a more valid set of beliefs
regarding the risk associated with obsessional situations. Once the patient
understands the importance of evaluating his or her logic, the therapist can
discuss how ERP techniques are designed to help gather additional evi-
dence that obsessional fears are less likely to materialize than had been
thought. An example of a Socratic dialogue between Susan and her
therapist is presented here.
Therapist: So, you are having lots of trouble using the toilet at school
where you work?
Susan: Yes. It seems like there are so many germs in the faculty bath-
room. So many people use that toilet, it’s probably not safe.
Therapist: Can you tell me specifically what you think might happen if
you used the toilet?
Susan: I am afraid of catching something from the toilet seat.
Therapist: Like a disease or a cold?
Susan: Hmmm. I never thought about exactly what might happen. I
suppose I would get very sick from the toilet germs and pass
them to my family.
Therapist: Would you and your family die from the toilet germs?
Susan: Probably not, but we would be very, very sick.
Therapist: OK. How about the other teachers you work with. How do
they feel about that particular toilet? Do they avoid it too?
Susan: Not really. I know most of them use the bathroom during
school hours. I’ve seen them excuse themselves to go there
sometimes.
Therapist: Hmm. So, then I guess these other teachers must get sick a lot,
right?
Susan: (thinks) … Well, I don’t think they get sick very often. In fact,
one of them always wins the award for perfect attendance.
Therapist: Interesting. So what does that say about using the toilet in the
faculty bathroom if other people use it routinely and don’t
seem to be getting sick all the time?
Susan: Well, maybe it’s not as dangerous as I thought. I never
thought about it that way before. But still, what if I am more
susceptible to germs than other people are? Doesn’t it make
sense to avoid it just to be on the safe side?
Therapist: Well, I agree with you that the toilet is probably not as danger-
ous as you think. Otherwise the people who used it would be
getting sick all the time. As far as being more susceptible, I
don’t know if you are or not. What makes you think that you
are more susceptible than someone else might be?
Susan: Nothing really. I guess I’m just afraid of the germs.
Therapist: Yes, I agree with you. There really is no good reason to think
you are more susceptible. It sounds like you are letting your
fear do the thinking for you (emotional reasoning). So, I’m
glad you recognize that you have been overestimating the
dangerousness of the toilet. That’s probably what leads you to
be fearful and avoid. The exposure therapy exercises I will as-
sist you with later on are going to help so that you will be able
to go to the bathroom, if you need to, and not be so fearful.
Therapists should be alert for two kinds of objections patients sometimes

raise when their overestimates of threat are challenged. First, some individu-
als reason that although feared outcomes may be unlikely, they still could oc-
cur. So, taking precautions such as avoidance and rituals seems prudent. For
example, one individual with contamination obsessions argued that it was
worthwhile for him to wash his hands periodically throughout the day be-
cause it was “better to be safe than sorry.” Another explained that although
she knew the chances of her computer or television catching fire were “one in
a million,” she could be that “one.” Such thinking indicates that the patient is
still ignoring important evidence of low risk. Thus, such evidence should be
revisited. To counter the “one in a million” argument, therapists can direct
the conversation toward correcting the faulty beliefs that the patient’s per-
sonal chances of being harmed are higher than that of other people in compa-
rable positions (e.g., coworkers, family members) who do not have similar
fears. Where appropriate, it can also be pointed out that people routinely face
more “dangerous” situations without suffering the dreaded consequences;
such as nurses and doctors who are routinely exposed to blood or dead bod-
ies; forensic pathologists and morticians who work with corpses; and waste
management workers, electricians, and fumigators who are routinely ex-
posed to pesticides and other potentially dangerous substances.
The second kind of rebuttal is based on the belief that safety behaviors
have prevented disastrous outcomes from occurring. For example, a pa-
tient with unwanted impulses to harm her baby might say that she did not
act on the violent thought because she canceled it out (neutralized it) with a
“safe” thought. In such cases the therapist must help the patient under-
stand the mechanism by which safety-seeking behaviors serve to reinforce
overestimates of threat. Specifically, safety-seeking behaviors are normal
responses when threat is perceived. Anyone who thinks they are likely to
murder their child, become sick, or be responsible for a terrible mistake
208 CHAPTER 9
would do what they could to avoid such adversity. People leave a burning
building as quickly as they can. However, if the perception of danger is
based on a misinterpretation of the situation (or thought), then the avoid-
ance or safety-seeking behavior prevents the person from finding out that
his or her fear is groundless. So, following circumstances that should dem-
onstrate that a feared consequence is unlikely, a person with OCD will be-
lieve that he or she narrowly escaped tragedy because he or she performed
a ritual to make things safe. This can lead to a discussion of the use of ERP
techniques to obtain a nonbiased perspective on the likelihood of feared
outcomes and ultimately correct overestimates of threat.
Overestimation of Responsibility. On some level, concerns about

being responsible for others’ safety seem sensible, if not imperative. Yet
patients sometimes have difficulty drawing the distinction between fail-
ing to do everything to prevent possible harm (e.g., rechecking the floor
for wet spots and warning people about them) versus actually inflicting
harm (e.g., deliberately causing someone to slip). Overestimation of re-
sponsibility actually consists of two types of distortions: First is an in-
flated sense of the amount of responsibility one has in the situation (e.g.,
“If a person slips on the floor it is completely my fault”). Second is an in-
flated sense of the consequences of being responsible (e.g., “If someone
slips, I am liable for negligence”).
The therapist can help the patient gain perspective on his or her own role
in causing negative events by having the patient identify all possible con-
tributing factors and then rate how much each factor contributes (what per-
centage) to the overall responsibility for the negative event. Van Oppen and
Arntz (1994) recommended incorporating this information in a pie chart to
visually illustrate the logical error. Figure 9.1 illustrates the use of this
method for a female patient who was afraid that because of her careless-
ness, a child (not her own) would ingest her medications and die. This pa-
tient believed that she alone would be responsible if her pill container
broke, some of her medication fell on the floor, and a child ate some of the
pills. First, factors (other than herself) were listed that would contribute to
such an event. The patient cited the bottle manufacturer, the child, and the
child’s parent for not keeping an eye on the child. Next, she rated the per-
centage of total responsibility attributable to each of these contributions
(25%, 25%, and 40%, respectively) and drew these in as pieces of the pie on
the whiteboard. Finally, the patient labeled the leftover part of the pie as her
own contribution (10%) and was able to acknowledge that even by her own
ratings, her responsibility for this imagined event was quite minimal.
Significance of Thoughts and TAF. The therapist should introduce to

the patient the concept of TAF as a habit of lending undue (negative) signifi-
FIG. 9.1. The pie chart method to illustrate factors that could contribute to
a child’s death by ingestion of medication that was accidentally dropped on
the floor.
cance to otherwise inconsequential intrusive thoughts. Behavior such as

avoidance, checking, and other safety-seeking strategies (e.g., neutraliz-
ing) would be expected if unwanted unacceptable thoughts are believed to
be important or have disastrous consequences. Socratic dialogue can in-
clude questioning to help the patient develop more ambivalence about the
importance of his or her thoughts; for example, “Are all of your thoughts
important, or just those about your infant?” and “What makes some of your
thoughts more important than others?” The aim of this conversation is to
make it apparent that not all of our thoughts are significant just because we
think them; and that the patient has many thoughts that (a) he or she would
not consider particularly important and (b) do not have external conse-
quences. The therapist can then ask the patient about more appropriate
ways to interpret obsessional thoughts in light of knowing that such
thoughts are normal and do not portend danger.
Individuals with unacceptable violent, blasphemous, or sexual obses-
sions may harbor the idea that thinking about dishonest, disgusting, and
dreadful events is morally equivalent to carrying out the corresponding be-
haviors (moral TAF). Such beliefs indicate the need for additional discus-
sion regarding the normalcy of intrusive upsetting thoughts. It might be
useful to ask patients what they would think if they found out that someone
they considered highly virtuous, ethical, or kind entertained a similar
210 CHAPTER 9
“bad” thought from time to time. If a double standard is present (e.g., “It’s
OK for someone else, but not for me, to think bad thoughts”), this should be
pointed out and possible alternative explanations generated. The patient
can be asked how he or she might explain that seemingly “good” people
sometimes have “bad” thoughts.
If the patient believes that unwanted thoughts will lead to the corre-
sponding event, the therapist can inquire about the mechanism by which
this could occur:
• How do you think your thoughts of raping another man will lead you
to commit this action?
• How will thinking about your mother getting cancer make her actu-
ally get cancer?
The goal here is not to put the patient on the spot, but rather to help him
or her conscientiously reflect on beliefs and assumptions that might be
taken for granted. Logical inconsistencies can be explored in a Socratic way
to facilitate the correction of such beliefs:
• If thoughts lead to actions, how are people able to maintain control of

themselves when they get angry or sexually aroused?
• Can you recall a time when you prayed, hoped, or wished for some-
thing and it didn’t happen?
A related issue is the ecological validity of obsessions; that is, obsessions

are incongruent with the patient’s worldview. People intent on harming a
baby would not be worried if they thought about the harm they were about
to inflict. An atheist would not be concerned over blasphemous images. A
gay person would not become upset over sexual images involving a
same-sex partner. Thus, Socratic discussion can focus on the “kinds” of
people who would and would not be concerned about violent, blasphe-
mous, or sexual thoughts. Does the patient have a history of behavior or
thoughts consistent with the obsessions? What evidence is there that the
patient has acted or will act on the thought?
To help the patient recognize the faulty logic of TAF thinking, he or she
can be given an object and asked to think about throwing it across the room.
The patient might be asked to visualize throwing the object or even say out
loud, “I want to throw the ____.” The patient’s restraint is then used as a ba-
sis for discussing the process by which one decides to act. Thoughts alone
do not translate to impulsively engaging in improper behaviors. This and
other similar exercises (e.g., going outside and “wishing” for car accidents,
thinking of throwing a ball through the therapist’s window, buying a lot-
tery ticket and thinking of winning) provide a robust demonstration that
thinking about an event has no direct or automatic causal influence. More-

over, it facilitates openness to engage in ERP exercises to reduce fears of
intrusive thoughts.
Need to Control Thoughts. The effects of thought suppression should

take center stage in addressing the need to control obsessive thoughts. Pa-
tients should understand how their misinterpretations of obsessions as
dangerous, morally unacceptable, or otherwise significant lead to desper-
ate and intense attempts to resist or remove such thoughts from conscious-
ness. In the short term, if successful, this might make the patient feel more
in control of his or her thoughts. It may also reduce the perceived probabil-
ity of feared consequences. However, patients must be taught how thought
suppression attempts paradoxically exacerbate obsessional problems as
explained in chapter 4. Moreover, for patients who are unaware that
thought suppression attempts often fail, the occurrence of mental intru-
sions despite tenacious efforts to banish them may lead to further negative
appraisals (e.g., “My mind is out of control”; Purdon et al., 2005) and inten-
sified efforts to suppress. The result is a self-maintaining cycle of suppres-
sion attempts, increased intrusions, and anxious thinking that results in
greater frequency and severity of the unwanted thought.
A robust way of demonstrating how attempts to suppress unwanted
obsessional thoughts backfire is to engage the patient in a brief experi-
ment as follows:
Therapist: Let’s try an experiment. I’d like you to not think of a pink ele-
phant for one minute. So, try to think of anything else in the
world except for a pink elephant. OK?
Invariably, the patient will have pink elephant thoughts and agree that it
is nearly impossible to fully suppress them (I have never had this experi-
ment fail!). Next, the patient can be asked about how this phenomenon ap-
plies to OCD symptoms. Such a discussion should focus on how thought
suppression attempts are unnecessary because obsessive thoughts are not
inherently dangerous in the first place. However, attempts to suppress are
doomed to fail and therefore they directly contribute to the escalation of
normal intrusive thoughts into clinical obsessions. In addition, the more ef-
fort the patient invests in trying to control or suppress, the more the un-
wanted thoughts will surface. Thus, the patient should expect for
intrusions to recur when efforts to suppress them are intensified.
This exercise, and the patient’s newfound knowledge that intrusive
thoughts occur normally and are not dangerous, leads nicely into present-
ing a rationale for the imaginal exposure techniques used in therapy. For
example, the patient can be asked, “If trying to suppress obsessional
212 CHAPTER 9
thoughts only makes the problem worse, and if obsessional thoughts aren’t
dangerous in the first place, what do you think would be a more healthy
way of dealing with your unwanted thoughts?” The answer is that learning
to embrace such thoughts as a normal part of life, rather than trying to con-
trol them, will reduce obsessional fear. The problem is not that the thoughts
are present, it is how they are appraised and dealt with. In imaginal expo-
sure, the patient will practice confronting his or her intrusions and refrain-
ing from safety behaviors to gain evidence that such thoughts do not
portend negative consequences.
Intolerance of Anxiety. Some people with OCD believe that feeling

anxious is dangerous because it will prevent them from functioning, make
them “lose control,” or that it will persist forever and spiral to unmanage-
able levels. Such beliefs understandably present a barrier to successful ERP
and should be addressed prior to beginning such exercises. When intoler-
ance of anxiety is identified, therapists can adopt materials from cogni-
tive-behavioral treatment manuals for panic disorder (e.g., Craske &
Barlow, 2001) that aim to educate patients about the physiology of the anxi-
ety response. In particular, patients are taught that anxiety is a normal emo-
tion designed by nature to protect the organism from danger. Anxious
(sympathetic) arousal, often called the fight-or-flight response, involves
the onset of numerous somatic symptoms that may seem uncomfortable or
scary (e.g., racing heart, dizziness, numbness and tingling, sweating), but
that are not at all dangerous (indeed the response is designed to protect the
organism). Myths and misinterpretations about the harmful effects of anxi-
ety symptoms can be addressed by assessing catastrophic beliefs about
harm from long-term anxiety (e.g., “My nerves will get fried out”) and by
providing corrective information about the feared somatic sensations and
their actual functions. Therapists can also have the patient describe previ-
ous experiences with anxiety to illustrate how such sensations subside over
time and do not result in marked functional disability or loss of control.
If the patient experiences panic attacks and agoraphobic avoidance, it is
worthwhile spending as much time as is needed to normalize the anxiety
response. Doing so will increase compliance with ERP because these proce-
dures require tolerance of prolonged anxious arousal. Exposure to obses-
sional cues might even be preceded by interoceptive exposure that involves
direct confrontation, in a systematic and controlled way, with feared so-
matic sensations. This exposure format, which is well described in panic
disorder treatment manuals (e.g., Craske & Barlow, 2001) is designed to
demonstrate that anxiety-related sensations are transient and harmless.
The “Just Right” Error. Perfectionism in OCD is characterized by be-

liefs that minor flaws, or even the sense of imbalance or imperfection, can
have serious negative consequences including that associated distress will
persist forever. In discussing such beliefs, the therapist can help the patient
recognize disadvantages of an “all-or-nothing” approach, including its fu-
tility given that absolute perfection can be rarely attained. Other instances
(that are unrelated to OCD) in which the patient does not demand perfec-
tion, and yet there is no associated distress, can also be discussed. Thus, the
patient may “know” how to manage imperfection and must learn to apply
this skill to his or her OCD concerns. Sometimes perfectionism interferes
with the patient’s ability to complete therapy assignments; that is, in trying
to do them perfectly, patients fail to benefit from them. In such instances the
patient should be encouraged (or assigned) to complete such tasks imper-
fectly and observe whether this leads to feared outcomes (e.g., failure to
benefit from treatment, unremitting anxiety).
Emotional Reasoning. In emotional reasoning the patient uses his or

her feelings of anxiety as evidence to support catastrophic thinking. In
other words, “If I am anxious, there must be danger.” For example, an indi-
vidual has the intrusive doubt that she may have left the oven on at home,
and that her house will burn down. If she misinterprets this thought as
highly significant and requiring action, she will develop obsessional anxi-
ety. She might then fall prey to emotional reasoning by thinking along these
lines: “I’m nervous. I’m afraid. There must be a good chance that something
terrible will happen. If not, why would I feel so afraid? I’d better go back
and check that the oven is off.”
The problem with emotional reasoning is that feeling anxious is not firm
evidence of danger. Obsessional fear is the result of a misinterpretation of
low risk situations and stimuli as threatening. Because emotional reason-
ing can prevent one from realizing the difference between feelings and
facts, the patient should be taught to recognize when emotions are being
used to validate fears and urges to perform compulsive rituals. Some pa-
tients articulate that they “know” their obsessional fears are senseless, but
that when very anxious, they cannot resist performing compulsive rituals.
To this end, the therapist can use Socratic dialogue to help the patient recog-
nize that the probability of a feared outcome (e.g., sickness, fires) remains
the same regardless of whether or not one is feeling anxious.
DISCUSSING HOW SAFETY BEHAVIORS

MAINTAIN OBSESSIONAL FEAR
The counterproductive effects of safety behaviors should be thoughtfully
discussed to promote adherence with response prevention instructions.
Handout 9.3, which succinctly summarizes this information, can be re-
viewed by the patient between sessions and subsequently discussed with the
therapist. Susan T.’s therapist began by quizzing Susan on the functional re-
lationship between obsessions and compulsions. Using impromptu oral
UNDERSTANDING HOW OCD WORKS
Obsessive-compulsive disorder (OCD) is an anxiety disorder, meaning that it
involves excessive, irrational, or unreasonable fear and anxiety. Anxiety is typically
associated with the anticipation of future negative events; for example, “What if
____ happens?” Other anxiety disorders include phobias (e.g., fears of
thunderstorms or heights); panic attacks, and generalized anxiety disorder, which
involves uncontrollable worries about situations such as work, health, or finances.
In OCD, people have unwanted or senseless thoughts (obsessions), and urges to
perform behavioral or mental rituals (compulsions).
Researchers have been interested in understanding the causes and
symptoms of OCD, and thus have conducted numerous studies on this topic
beginning in the middle of the 1960s. This research has confirmed two
important facts about OCD: (a) obsessions evoke anxiety and (b) compulsive
rituals (for the most part) reduce anxiety. This handout explains these
important relationships in more detail. The explanations can be divided into
two parts: (a) how obsessional fears develop, and (b) why obsessional fears
persist.
OBSESSIONS
Obsessions are unwanted intrusive thoughts, ideas, or images that evoke
anxiety, worry, or discomfort. Their content is usually senseless or bizarre— and
the person often (but not always) recognizes this. People with OCD try to resist
their obsessions, meaning that they try to stop the thoughts, often
unsuccessfully. Broadly speaking, obsessions usually concern the possibility of
danger, harm, or responsibility for danger or harm. Their specific content may
focus on aggressive actions, contamination, sex, religion, mistakes, physical
appearance, diseases, and need for symmetry or perfection, among other
topics.
PART 1: WHAT CAUSES OBSESSIONS?
You may be surprised to learn that just about everyone, whether or not they
have OCD, experiences intrusive, upsetting, unwanted thoughts from time to
time. Indeed, human beings have many, many thoughts while awake and
during sleep—some are positive thoughts and others are negative ones. This is
entirely normal. What is also normal is that sometimes our brains focus on
bizarre or senseless thoughts or ideas. In one research study, groups of people
with OCD and without OCD were asked to list some of their unpleasant, bizarre,
or senseless unwanted thoughts (people with OCD were asked to list their
obsessions). The researchers then gave the lists of thoughts to psychologists
and psychiatrists and asked them to try to distinguish between the thoughts of
people with and without OCD. The results might be surprising: Even these
mental health professionals did a poor job of determining whether the thought
was from someone with OCD or someone without OCD. Again, this confirms
that people with OCD and those without all have upsetting, unwanted thoughts.
On the next page are listed several examples of intrusive thoughts reported by
people without OCD:
Handout 9.3. Understanding how OCD works. (continued)

214
•The impulse to harm a loved one •Doubts about having committed a sin
•Thoughts of accidents involving loved ones •Thought of being punished by God
•Thought of harm coming to one’s children •Impulse to curse in church
•Impulse to jump in front of an oncoming •Thoughts of accidents or mishaps
vehicle •Thoughts of children getting sick
•Impulse to shout rude or inappropriate •Thought of “unnatural” sex acts
things during a performance •Thought about molesting children
•Thought about harm from asbestos •Images of germs festering on one’s skin
•Impulse to shout at someone or abuse •Sense that something is not perfect
them •Bad thoughts about God
The fact that everyone experiences intrusive, distressing, or senseless thoughts

means that people with OCD do not have something terribly wrong with their
brains that cause them to have these kinds of thoughts. And, this is good news
because it suggests that people with OCD are not suffering from a “brain abnor-
mality.” Their thoughts are no different than the thoughts of people without OCD.
Of course, there is no question that people with OCD do experience their
upsetting thoughts more frequently and as more distressing compared to people
without OCD. The reasons why this is so are explained below.
You might also be wondering why these strange but completely normal negative
intrusive thoughts exist in the first place. This is probably due to the fact human
beings have highly developed and creative minds. We are able to imagine all
kinds of scenarios—some more pleasant than others. The “thought generator” in
our brains sometimes generates thoughts we would rather not think about.
Sometimes, the generator produces thoughts about harm, immorality, or danger
even though there may not be any real threat present.
DIFFERENCES BETWEEN PEOPLE WITH AND WITHOUT OCD
If intrusive distressing thoughts are a normal part of life for everyone, every
day, why do some people develop OCD and others do not? It turns out that
scientists have discovered differences in how people with and without OCD
interpret their unwanted negative thoughts. First, let’s consider what people
without OCD do with their unwanted thoughts. Research shows that people
without OCD typically dismiss their intrusive, unwanted thoughts as insignifi-
cant, meaningless, and not worthy of any further attention. In response to
such a thought, they might automatically say to themselves, “That’s a silly
thought, I would never do that,” or “That thought doesn’t make sense—time
to think about something else.” When this happens, the person doesn’t pay
any more attention to the thought, and the thought soon passes.
But things go much differently for people with OCD. Studies have found that
people with OCD misinterpret their intrusive thoughts as highly meaningful or
significant in one way or another. In fact, many people with OCD view their
intrusive thoughts as threatening or immoral. When this happens, it activates
the body’s automatic danger detection system (the “fight–flight” system),
which causes us to pay more attention to the perceived threat. But, as we
learned above, the thoughts are not actually dangerous—they’re normal. So,
the danger detection system doesn’t actually need to be activated (there is no
actual threat to be protected from). The result is that the person feels as if
Handout 9.3. (continued)

215
there is a tiger lurking around the corner, when there is really only a kitten. So,
it is not surprising that people with OCD pay lots of attention to their upsetting
unwanted negative thoughts. This obsessional preoccupation occurs
because the thought is perceived as threatening and paying attention to
threat serves a protective mechanism.
So, as you can see the main difference between people with and without OCD
is in the importance that they attach to their intrusive thoughts—not the
thoughts themselves. It is no coincidence that we typically see contamination
obsessions among clean people, harming obsessions among nice people,
sacrilegious or sexual obsessions among strictly religious or moral people, and
thoughts about mistakes among careful people. The more important something
is, the worse it seems to have a bad thought about it.
THINKING PATTERNS IN OCD
It turns out that most people with OCD have similar problematic patterns of
thinking that lead them to misinterpret their intrusive thoughts in ways that lead to
feeling threatened. Below, we will explore some of these thinking patterns.
Inflated Sense of Responsibility
People with OCD often feel overly responsible for harm or danger associated
with their obsessions. They may feel as if they have a special responsibility to
reduce the chances of something terrible happening. But they do not stop to
evaluate the realistic probability of danger—which is usually extremely low. So,
people with OCD often act on the blind assumption that their intrusive
obsessional thoughts are true (which, as we have seen, is not the case). In
addition, whereas people without OCD typically assume a situation is safe if
there is no recognizable sign of danger, people with OCD assume obsessional
situations are dangerous and require excessive assurance that they are, in fact,
safe. Thus people with OCD have an “intolerance of uncertainty.”
Oversignificance of Thoughts
Another error that people with OCD sometimes make is to believe that it is bad
to have “bad thoughts.” As we have seen above, this is simply not true. As
human beings, we are fortunate to have the capacity to think about anything we
want. We can plan ahead, remember, and create fantasies about both positive
and negative events. Everyone at times has unpleasant thoughts about things
we might consider inappropriate or immoral. Whereas there might be
consequences for acting on these thoughts, we are completely free to imagine
such events without consequences. Indeed, most movies, shows, books,
artwork, and science are the result of this wonderful ability to think creatively.
“Bad” Thoughts Lead to Bad Behavior
Some people with OCD fear they will automatically “lose control” and act on
their obsessional thoughts without thinking. So, having a “bad” thought is
perceived as dangerous because it will lead to a terrible action. However, this is
not true. Our thoughts are not the only determinant of our actions. Indeed, we
have the free will to pick and choose which thoughts we will act on and which
we will not. Thoughts about inappropriate or harmful actions (that you don’t
want to act on) cannot actually cause you to act against your will.
216
Magical Thinking and Emotional Reasoning
Another problematic thinking pattern is “magical thinking”—believing that if
you have a thought about an event, it makes the event more likely to happen.
But, just because we think of something does not make it more likely to occur.
Think of how many times you think about something and it doesn’t happen.
Another mistake is emotional reasoning—the tendency for people with OCD
to base their beliefs on what they feel, rather than on what other kinds of valid
evidence tells them. An example is the following: If I feel anxious, I must really
be in danger. But this is backward logic. Just because you feel a certain way
doesn’t make it true.
The Need to Control Thoughts
Another common mistake is to believe that you can, and should, control your
thoughts. This is also not true. In fact, human beings are poor at controlling their
thoughts. You might know this firsthand if you have ever tried to stop yourself from
having a specific thought—this is called thought suppression. Most likely you found
that attempts to suppress your unwanted thoughts resulted in the thought coming
back. Researchers have studied thought suppression extensively, finding that
people cannot stop their thoughts by simply telling themselves not to think them.
So, using this strategy with obsessions is doomed to fail also. In fact, one of the
ways obsessions can develop is by habitually trying to suppress thoughts. If you
believe a thought is dangerous and try to suppress it, but can’t, you will start to feel
more and more anxious. However, if you believed 100% that your unwanted
thoughts are not threatening, you would not have the need to control or suppress
them, and the thoughts would actually occur less frequently.
A MODEL OF THE DEVELOPMENT OF OBSESSIONS
What we have described so far helps to explain how obsessional thoughts
develop. A simple model of the development of obsessions would look like
the following:
PART 2: WHY DO OBSESSIONAL FEARS CONTINUE?

This brings us to the second part of our explanation: how obsessions continue.
Once a fear or obsession is established, people naturally seek to reduce their dis-
comfort. If a person feels threatened, he or she will act to remove the threat. People
with OCD generally use two strategies for removing threat caused by unwanted
thoughts. The first strategy is to avoid threatening situations or thoughts in the first
place. The second is to escape from unavoidable situations or thoughts. As we will
see, both have the same eventual outcome—they actually strengthen obsessional
fears. We will focus on avoidance first.
AVOIDANCE
People with OCD spend a lot of energy avoiding situations that provoke obses-
sional anxiety. This is understandable because no one wants to feel anxious or
217
threatened. Avoidance may be subtle, such as turning the channel on the
television or not touching a certain surface; or it may be overt, such as driving out
of your way to avoid passing a certain landmark. Thus, avoidance tends to be
one of the more devastating aspects of OCD because it can severely restrict
people from their normal functioning. The purpose of avoidance in OCD is to
dodge confrontation with feared situations featured in obsessional thoughts and
reduce the likelihood of anxiety and harm. So, there is a relationship between
obsessional thoughts and situations that are avoided. However, as we have seen
above, obsessional fears are unrealistic. Thus, avoidance is an exaggerated
response to situations that pose little if any real threat.
Not only is avoidance an excessive response to obsessions, it also strengthens
obsessional fears in three ways. First, because it requires effort, avoidance calls
greater attention to the obsessional thought. You start to believe “If I have to go
to so much effort to avoid, it must be important” (this is a form of emotional
reasoning). Second, avoidance leads to being overly watchful, or
“hypervigilant,” for possible things you must avoid. This results in paying more
and more attention to the fearful things you must avoid, which leads to noticing
more obsessions. Third, avoidance prevents you from learning that your
obsessional fear is not valid. That is, by avoiding, you never give yourself the
opportunity to enter a feared situation and see that (a) harm is unlikely to occur,
and (b) you can handle temporary anxiety and discomfort that eventually goes
away. Thus, avoidance contributes to the continuance of obsessional fears.
COMPULSIVE RITUALS AND SAFETY BEHAVIORS
If a threatening situation cannot be avoided, people with OCD try to escape
from their obsessions using certain strategies called “rituals” or “safety
behaviors.” These behaviors often take the form of repeated washing,
checking, praying, arranging, mentally neutralizing, repeating, and asking for
assurance. They are all performed with the aim of reducing obsessional
anxiety, uncertainty, and the perceived possibility of danger. For example,
people with obsessional fears of contamination from floors might avoid
touching floors. But if they happen to come into contact with the floor, they
might wash their hands to remove the feared contamination. After the
washing is completed, the people feel less anxious.
It is important to consider that it is perfectly natural to want to escape from
potential harm—people try to leave a burning building as quickly as they can!
So, safety behaviors in OCD are understandable. The problem, however, is that
they are based on a mistaken belief about danger. That is, if there is a very slim
probability of harm from touching the floor, then hand washing is unnecessary.
This is the main problem with compulsive rituals and other kinds of safety
behaviors—they are excessive and unnecessary.
As with avoidance, compulsive rituals and safety behaviors serve to
strengthen obsessional fears. First, you may have come to believe that
“something worth ritualizing about must really be dangerous” (emotional
reasoning). Second, if compulsive rituals serve as an escape from perceived
danger, by performing rituals you never give yourself the opportunity to see
that the obsessional situations are not dangerous. Third, people with OCD
often come to believe that their rituals really prevent the disastrous
consequences they fear. In the example above, the person might believe, “I
218
did not get sick because I washed my hands.” This is a dangerous trap
because not only is it a false belief (the floor probably wasn’t going to make
you sick in the first place), but it leads to strong feelings that the ritual is
important for keeping safe. Thus, safety behaviors are maladaptive because
they reinforce obsessional fears.
A final point about compulsive rituals is that they seem to be effective for reducing
anxiety in the short term. That is, after performing a ritual, you might feel a sense
of relief or completion. When this occurs, it means you have tricked yourself into
believing that you have just averted catastrophe. As we have seen, there was no
threat to avoid in the first place, so this feeling is superstitious. However, the feeling
of relief is important because it quickly leads to more urges to complete this ritual
the next time you feel threatened. That is, because the ritual made you feel better,
you learn to do it again to escape threat under similar circumstances in the future.
Psychologists call this “negative reinforcement.” This is how rituals become a strong
habit. In the long term, however, rituals are wasteful because they teach you to use
excessive, time-consuming, and meaningless tactics to reduce fear and distress.
So, you can see how avoidance and compulsive rituals, by virtue of their ability to
reduce fear and distress, help to strengthen OCD symptoms of obsessional fear.
If we think of a model of OCD that incorporates rituals and avoidance, we have
the following:
Misinterpretations of normal, harmless intrusive thoughts lead to increased
fear and urges to reduce the fear by ritualizing or avoiding. Rituals reduce the
fear in the short term, but reinforce the misinterpretation of obsessional fears
and situations as dangerous. Thus, opportunities to learn that your fears are
unfounded never occur. Obviously, then, once you believe that obsessional
situations and thoughts do not represent a high risk of harm, you will feel
fewer urges to avoid situations or perform compulsive rituals.
Cognitive-behavior therapy (CBT) is a treatment based on this idea and will

help you to (a) correct faulty beliefs that lead to obsessions, (b) weaken the
pattern of becoming anxious when you experience certain thoughts, and (c)
weaken the pattern of avoidance and performing compulsive rituals in
response to obsessional fear.

219
220 CHAPTER 9
examinations helps impart to the patient the importance of understanding

the conceptual model.
Therapist: Remember when we developed the model of your OCD

symptoms and we talked about the relationship between ob-
sessions and compulsions? Can you tell me the relationship
between obsessions, compulsions, and anxiety?
Susan: Sure. My obsessions increase my anxiety and my compul-
sions decrease it temporarily. But the compulsions don’t
work because after a while I get more obsessive fears.
Therapist: Very good. Also, there are other strategies you use that have
the same effect as compulsive rituals. These include avoid-
ance, like how you avoid contact with the “dirty” child in
your class, and subtle rituals we call neutralizing, such as
when you try to force out of your mind the unwanted
thoughts of hurting baby Jennifer. Collectively, we call these
behaviors safety behaviors because they make you feel
safer—like you have narrowly averted catastrophe. It is this
sense of safety that decreases your anxiety.
Many patients view their avoidance and compulsions as bizarre, auto-

matic, and uncontrollable behaviors. Thus, the therapist next helped Susan
to see that such behaviors are actually understandable and predictable for
someone who believes himself or herself to be in serious danger. Of course,
the problem is that objective danger does not exist in the first place. Thus,
these responses are redundant.
Therapist: At various times you might have thought that your avoid-
ance and rituals seemed so strange as to defy logic, or that
they are out of your control. However, these are actually very
normal responses for someone who feels as if they are in dan-
ger, or as if they hold the responsibility for preventing some-
thing terrible. No one likes feeling anxious, so we do
whatever we can to avoid threatening situations, and if we
can’t avoid them, we do whatever we think will make us feel
better or safer. For example, if you are afraid you will make
your family ill by bringing home germs from the “dirty”
child in your class, it is sensible that you avoid him. Similarly,
if you are afraid that you have assigned a student the wrong
grade, checking that this hasn’t happened seems like a good
idea. Do you see what I mean?
Susan: Yeah, but why do I do these things to such extremes?
Therapist: That’s a good question. Let’s talk about avoidance first.
When you avoid situations that are not as really dangerous as
they seem, it tricks you into thinking that you averted a catas-
trophe. So it makes you feel less anxious. For example, you
think the faculty bathroom at work is likely to make you sick.
So, if you avoid it and then you don’t get sick, you will think
that you didn’t get sick because you avoided the bathroom.
So, you continue to avoid the bathroom, as well as other
things that you connect with the bathroom. The problem with
so much avoidance is that it keeps you from ever finding out
whether or not the bathroom is really as dangerous as you
think. In other words, when you avoid, you never have the
chance to disprove your fears. You also never have the chance
to see that your anxiety about the bathroom, and other situa-
tions, would eventually go away on its own if you didn’t
avoid. So, you keep avoiding and it becomes a habit.
Next, the therapist helped Susan to understand the effects of performing

compulsive rituals and how rituals develop their repetitive nature.
Therapist: If you could, you would probably avoid all of the things that
trigger your obsessional fears. However, it is hard to com-
pletely avoid obsessions because sometimes they are trig-
gered by situations that are not convenient for you to avoid. A
good example is grading papers, which as a teacher, you can’t
avoid. So, the next best solution is to search for a way to re-
lieve the anxiety as quickly as possible. For you, that means
rechecking grades or calling students’ parents to get reassur-
ance that their grade is correct.
Now, if, at some point, these checking strategies make you
less anxious, or make you feel as if you have dodged a bullet,
then you become more likely to use them over and over when
faced with the same obsessional doubt. And, each time you
use the strategy and your anxiety goes down, you strengthen
this pattern.
It is important to draw attention to subtle neutralizing strategies because

they are functionally equivalent to compulsive rituals in their ability to
propagate obsessive fear.
Therapist: Neutralizing strategies are another kind of maladaptive re-

sponse to obsessions that provide an escape from distress in
the short term, but that make things worse in the long run.
Neutralizing involves doing something to remove an un-
wanted thought, to control the thought, or get reassurance that
nothing bad will happen as a result of having the thought. You
222 CHAPTER 9
said that when you get thoughts of harming Jennifer you try to
force them out of your mind or ask for reassurance from others
that you will not hurt the baby. Again, these behaviors seem
like a good idea because you have the fear that you will act on
your violent thoughts. However, neutralization strategies are
maladaptive for a number of reasons. First, as we discussed
before, trying to suppress thoughts doesn’t work. So, then, you
start to worry that there is something terribly wrong since the
bad thoughts don’t go away even when you try to force them
out. Worse, each time you neutralize, you lend more attention
and importance to a thought that is really less important than
you fear. Finally, neutralizing prevents you from learning to
examine your thoughts closely and finding out that the obses-
sional anxiety will eventually decrease on its own.
Once the patient understands the antecedents and consequences of

avoidance, rituals, and neutralizing, the therapist can help him or her
think of these behaviors as patterns that can be weakened with practice.
This is a critical point because response prevention will entail refraining
from all of these behaviors to learn that obsessional fears are unfounded.
To this end, it is useful to reframe avoidance, compulsive rituals, and neu-
tralization strategies as ill-advised choices the patient makes when faced
with obsessional triggers. Thus, by choosing not to avoid, ritualize, or
neutralize, the patient would create opportunities to confront feared situ-
ations and thoughts and learn that these stimuli are not as dangerous as he
or she thinks. This issue is discussed in greater detail in the chapters de-
scribing the use of ERP techniques.
WHEN TO USE COGNITIVE TECHNIQUES

As shown in Table 9.3, the cognitive techniques described previously can
and should be used throughout the course of therapy. Socialization to the
cognitive-behavioral model should occur during the assessment and con-
ceptualization phase via discussions about the normalcy of thoughts and
how mistaken interpretations evoke obsessional fear and compulsive
urges. Because of the importance of rapport building during the initial ses-
sions it is probably best to refrain from strongly challenging the patient’s
dysfunctional beliefs early on in treatment. Instead, Socratic dialogue
should be used to amplify the patient’s ambivalence and help him or her to
recognize the inconsistencies in his or her thinking (“I am a murderer be-
cause of my terrible impulses” vs. “I have never acted on unwanted im-
pulses to harm people”). This helps to induce a sense of cognitive
dissonance that the patient can later be helped to resolve through Socratic
discussions and ERP. Along these lines, patients should be informed that
TABLE 9.3
Opportunities to Use Cognitive Therapy Techniques
During the Psychological Treatment of OCD
Phase of Treatment Purpose of Cognitive Techniques

Assessment/information Socialize the patient to the cognitive-
gathering/formulation behavioral model, build rapport
Treatment planning Prepare the patient for confronting feared
situations during exposure and response
prevention
Exposure therapy sessions Facilitate cognitive change during and
after exposure
Reviewing homework assignments Identify and correct cognitive distortions
Follow-up/maintenance Consolidate and reinforce information
learned during the active phase of treatment
therapy is an open, collaborative process that requires a shared under-

standing of the problem and how it can be reduced. Psychoeducational dis-
cussions serve to reinforce this focus.
Exposure therapy sessions also afford numerous opportunities for infor-
mal discussions about mistaken cognitions. Cognitive change can be maxi-
mized during exposure by having the patient process, in cognitive terms,
his or her experience of confronting the feared situation and the evidence
that is being collected by performing the exercise. For example, the nor-
malcy of intrusive thoughts, futility of trying to achieve a guarantee of
safety, importance of risk taking, and the costs of avoidance and compul-
sive rituals can be discussed within this context. Socratic dialogue is best
used to help the patient articulate corrected beliefs about exposure stimuli
he or she once feared or avoided. Strong affect during exposure, whether
about the present exercise or the assigned homework practice, can also be
seen as an opportunity to use cognitive techniques. The emotional patient
should be asked to identify the thoughts and images running through his or
her mind at that moment. Next, a Socratic dialogue addressing mistaken
beliefs, assumptions, or interpretations can ensue. The therapist can also
point out and summarize changes in beliefs during and after the comple-
tion of an exposure exercise. Once the patient is well socialized to the cogni-
tive-behavioral model, he or she can be asked to provide such summaries. I
discuss in more detail the integration of cognitive techniques with
exposure exercises in the chapters on exposure therapy.
Reviewing self-monitoring forms at the beginning of each session pres-
ents another opportunity to use CT. In particular, the performance of rituals
indicates the presence of mistaken cognitions and should be discussed
224 CHAPTER 9
within the context of the cognitive-behavioral model; for example, “What

were you telling yourself about sitting on the sofa that made you decide to
change your clothes?” “How did you interpret the doubts about your faith
that led you to complete the prayer ritual?” or “What were the short- and
long-term consequences of your ritualizing?” Mistaken beliefs can be chal-
lenged using the available evidence and Socratic questioning.
Although not the primary focus of therapy, events outside the context of
treatment and issues related to the therapeutic relationship may also evoke
strong emotional responses. Here again, the therapist can help the patient
identify specific activating events (e.g., breakup of a romantic relationship,
nearing the end of therapy) and related thoughts, beliefs, and assumptions.
Socratic techniques can be used to help the patient challenge identified
thinking errors and generate more healthy alternatives.
10
Treatment Planning I: Rationale
and Hierarchy Development
Exposure therapy refers to a set of behavior therapy procedures in which

patients confront fear-evoking stimuli in real life (situational or in vivo ex-
posure), in imagination (imaginal exposure), or by other media (e.g., in vir-
tual reality, interoceptively [exposure to internal body sensations]) until the
associated fear is reduced. Response prevention, in which the patient re-
frains from safety-seeking behaviors such as rituals and neutralizing, is a
necessary accessory to exposure, as it prolongs confrontation with the
feared stimulus and teaches the patient that anxiety declines even if safety
behaviors are not performed. Chapters 10 and 11 present the procedures for
planning a successful course of ERP treatment. In this chapter, I describe
how to provide a coherent rationale for ERP and develop with the patient a
fear hierarchy of situations to be confronted during exposure sessions.
Chapter 11 covers how to devise a plan for response prevention, enlist a
support person to help the patient between sessions, and finalize the treat-
ment plan. Typically about 3 to 5 hours (therefore multiple treatment ses-
sions) is needed when planning for ERP. Here again, the case of Susan T. is
used to illustrate the techniques.
225
226 CHAPTER 10
PRESENTING THE RATIONALE FOR ERP
The therapist should begin treatment planning with a review of the concep-
tual model of OCD. To gauge how well the patient understands this model
it may be useful to ask questions such as these:
• What are your obsessions and what happens to your anxiety level
when they are triggered?
• What are your rituals (safety behaviors) and what do they do to your
anxiety level?
• Why aren’t your avoidance and safety behaviors helpful in the long
term?
When satisfied that the patient has a working understanding of the model,
the rationale for using ERP procedures to reduce obsessions and compulsions
can be presented. The rationale includes elements of both the behavioral (ha-
bituation) and cognitive explanations for how exposure reduces fear: By re-
maining in the feared situation and resisting rituals, the patient learns that
obsessional anxiety diminishes on its own, that feared consequences are un-
likely, and that an acceptable degree of uncertainty is manageable. This ratio-
nale is a crucial part of the psychoeducational process because it helps patients
understand why they should engage in a therapy that involves facing their
worst fears while dropping their safety nets. The rationale must therefore enu-
merate logical links between the patient’s OCD symptoms, the treatment pro-
cedures, and the anticipated outcome. It should also be individualized
according to the patient’s idiosyncratic symptoms.
Note that the purpose of exposure is not to reassure the patient that feared
consequences would never happen. Rather, it helps the patient learn that the
risks associated with obsessions are acceptably low. Therefore, safety strate-
gies such as avoidance, rituals, reassurance seeking, and neutralizing are re-
dundant and unnecessary. That the patient must learn to tolerate acceptable
levels of risk and uncertainty should be reiterated throughout therapy. Susan
T.’s therapist provided the following treatment rationale.
Therapist: The main treatment techniques we will use are called exposure
and response prevention and they are designed to weaken the
two patterns in OCD. The first pattern is the one of becoming
very anxious when you have obsessional thoughts. We will
weaken this pattern using exposure, which means that you will
practice gradually confronting the situations and thoughts that
evoke anxiety until they no longer make you feel so anxious.
The second pattern is that of using avoidance and rituals to re-
duce your anxiety. We will weaken this pattern by implement-
ing response prevention, which means helping you practice
TREATMENT PLANNING I 227
resisting the urge to do anything to get rid of the obsessional

anxiety except staying exposed to the situation.
So, for example, I will help you to practice confronting
things like bathroom germs and the student in your class who
you have been avoiding. At the same time, you will practice
resisting your urges to decontaminate yourself by washing or
showering. We will also practice working with students’
grades to help you refrain from checking, and we will help
you confront thoughts about harming your daughter.
The basic idea of exposure therapy is simple. Exposure
helps you learn three things. First, you will learn that your
anxiety does not stay at high levels forever or spiral “out of
control.” In fact, your anxiety will actually subside as you re-
peatedly confront a feared situation and remain exposed for
an extended period of time. This process is called habitua-
tion. You probably have never discovered this on your own
because you usually avoid or ritualize as quickly as possible.
In other words, you usually escape from the obsessional situ-
ation before you have the chance to see that your fear would
naturally decrease anyway.
The second thing you will learn is that the consequences
you fear as a result of exposure are much less likely to happen
than you have been thinking. So, you will see that you proba-
bly don’t get sick from bathrooms as easily as you had
thought, that you need not worry so much about assigning
the wrong grades, and that you are unlikely to harm your
baby despite your violent thoughts. This new learning is
what reduces obsessions, and doing exposure and response
prevention exercises will provide the opportunities for this
learning to take place.
The third thing you will learn during exposure is how to
manage uncertainty and doubt. Instead of needing a guaran-
tee of safety, this therapy will teach you how to live more
comfortably with acceptably low levels of risk that most peo-
ple take for granted.
At this point it is useful to draw a graph for the patient (or present him or
her with a handout) depicting the expected habituation curves over the
course of several sessions of exposure. Using a whiteboard, Susan’s thera-
pist drew and briefly explained the graph in Fig. 7.1 (p. 160).
Therapist: Exposure and response prevention are very helpful for re-
ducing OCD if they are done correctly. But this treatment is
hard work and you should expect to feel anxious at times, es-
228 CHAPTER 10
pecially when starting to confront the feared situations. For-

tunately, this anxiety is temporary. This graph shows what
we expect to happen when you repeatedly expose yourself to
obsessional situations. As you begin exposure for the first
time you will probably feel uncomfortable. It is at this point
that you typically perform a ritual to reduce your anxiety, but
over the course of an exposure session your anxiety level will
decline as habituation occurs. At the next session you will ini-
tially feel uncomfortable, but your anxiety will subside more
quickly because you have learned that habituation occurs. By
the time you have practiced exposure several times and in
different situations, your beginning anxiety level will be
lower and it will subside even more quickly because you
have learned that the situation is not as dangerous as you
thought. With repeated practice, the feared situations will no
longer provoke anxiety. Of course, this only happens if you
remain exposed and do not perform rituals or neutralizing
behaviors to escape from the anxiety prematurely. So, for ex-
posure to work, you must remain in the situation long
enough for anxiety to subside on its own. As I like to tell peo-
ple, you must invest anxiety now to have a calmer future.
There are two types of exposure that we will use. One type,
called situational or in vivo exposure, means confronting ac-
tual feared situations. We will do situational exposure exer-
cises both in the office and on field trips to places like public
bathrooms. I will also ask you to practice situational exposures
between sessions. When it is not possible to conduct situa-
tional exposure, I will help you to confront obsessional situa-
tions and thoughts in imagination using imaginal exposure.
Of course, I will do what I can to make the exposure exer-
cises as easy for you as possible without compromising the
effectiveness of the therapy. My job is to help you to succeed.
One way I will help minimize the unpleasantness is by devel-
oping with you a list of exposure situations that begins with
less anxiety-provoking situations and gradually works up to
those that are more difficult. Exposure will begin with situa-
tions that evoke less distress. In fact, you will have a large say
in when we conduct each exposure and I will always obtain
your permission before beginning each exercise. We will plan
these exercises together ahead of time so that there are no sur-
prises. I will also be there to support and coach you through
each in-session exposure. Nevertheless, you will still have to
tolerate some anxiety, at least initially, as you learn to weaken
your OCD patterns. Do you have any questions?
The therapist then described the nature of the therapeutic relationship so

that Susan knew what she could expect from her therapist:
Therapist: You can think of me as your coach and your cheerleader. As a

coach, my job is similar to that of a trainer or teacher. Did you
ever take lessons to learn how to play a sport or a musical in-
strument?
Susan: Yes. I took golf lessons for a long time.
Therapist: Excellent. Do you play golf now?
Susan: Yes. I’ve become pretty good at it.
Therapist: So, when you were learning how to play, your instructor, who
was probably an expert golfer, probably analyzed your swing
to look for things that needed to be corrected and then gave
you instructions for how to improve. He or she probably also
had you practice certain exercises over and over on the driv-
ing range or the putting green to help you learn to hit the ball
well. Now, if you didn’t practice the exercises the way the
teacher told you to, you would not have improved your golf
game. Also, your teacher probably never forced you to prac-
tice. You made up your mind to practice on your own because
you wanted to become a good golfer.
Therapy for OCD works the same way. As your coach or
teacher, I know the kinds of exercises you must do to reduce
your symptoms. We will build a program that is tailored to
your specific symptoms. If you follow the program the way
that I show you, chances are you will see improvement, but if
you decide not to practice the exercises in the correct way, the
chances are you will not improve as much as you would like. I
will never force you to do the exercises—this is your therapy
and the decision has to come from you. However, I might try
to help you see that your feared situations are not as danger-
ous as you think, and that it is in your best interests to ap-
proach, rather than avoid these situations.
At some point during treatment I might ask you to do
things that seem especially risky or that people don’t typi-
cally do in their daily lives. For example, sometimes I ask
people not to shower for an entire day or not to wash their
hands before they eat. I might also ask you to purposely
think distressing obsessional thoughts. It is important for
you to understand that the purpose of exposure and re-
sponse prevention is not just to practice doing what is nor-
mal or what most people do. The purpose of these exercises,
which are designed especially for you, is to weaken your
OCD patterns.
230 CHAPTER 10
I said that you could think of me as both a coach and a

cheerleader. In my role as cheerleader I will be behind you ev-
ery step of the way as you complete this challenging therapy.
We are a team and I will give you my support and do what-
ever I can to help you complete the exercises in a therapeutic
way. If you feel very scared, or if you feel like you are having
difficulty, I want you to let me know so that I can help you.
Similarly, if I think you are having a difficult time, I will step
in and help you out. What questions do you have for me?
DEVELOPING THE FEAR HIERARCHY
In planning for ERP, the therapist must engineer experiences in which the
patient confronts stimuli that evoke obsessional fears of disastrous conse-
quences, but where the feared outcomes do not materialize and the only ex-
planation is that the stimuli are not as dangerous as was thought. The
exposure treatment plan, or fear hierarchy, is a list of specific situations, stim-
uli, and thoughts the patient will confront during therapy. Prolonged expo-
sure to each hierarchy item, one at a time, is conducted repeatedly (without
safety behaviors) until distress levels are reduced to the point that the pa-
tient can manage adaptively with the situation. It is critical that hierarchy
items match the specific situational and cognitive elements of the patient’s
obsessional fears. For example, an individual with obsessions of hitting pe-
destrians with his car must expose himself to driving on crowded streets or
parking lots. If he believes such accidents are especially likely after dark, he
must practice this after nightfall. Practicing driving during the day will not
be effective in completely modifying the patient’s fear because if no one is
injured he might attribute this to the daylight, rather than recognizing that
he was unlikely to hit someone. The importance of closely matching hierar-
chy items to the patient’s fear cannot be emphasized enough; and this high-
lights the importance of careful ongoing assessment. Hierarchy items are
also ranked according to the level of distress that the patient expects to en-
counter during exposure to that particular item. So, for the patient just de-
scribed, exposure to driving near pedestrians during the day would be less
anxiety provoking than the same situation practiced at night.
Susan T.’s therapist introduced the concept of the fear hierarchy in the
following way:
Therapist: Our goal for today’s session is to begin planning for expo-
sure. To do this we need to make a list of the specific situa-
tions and thoughts that you avoid, or that make you feel like
doing rituals. These will be the situations that you will prac-
tice exposing yourself to during treatment. I’ll need your help
in making this list because you know best what kinds of situ-
ations and stimuli evoke your symptoms. Once we have our

list I’ll ask you to rank each situation according to how un-
comfortable you think it will make you. Then we can arrange
the situations in the order that you will practice them. You
can choose when you confront each situation, although I
might make certain recommendations to ensure that we get
the best possible results. Usually, the best approach is to be-
gin with easier situations and work up to the more difficult
ones. This list of situations is called a fear hierarchy and you
can think of working through the hierarchy as climbing up a
ladder. During each session you will take another step up the
ladder until you reach the top. I will also ask you to continue
practicing exposures between sessions. Treatment will be
most effective if we plan to go gradually, yet steadily, up the
ladder. Remember that I will help you at each step.
Situational (In Vivo) Exposure
Deciding on Hierarchy Items
Thoughtful and creative planning are the cornerstones of an effective

ERP program. Therefore, developing the in vivo exposure hierarchy re-
quires careful inquiry. Informed by the detailed information collected
during the assessment and information gathering phases (e.g., obses-
sional fears, situational cues, catastrophic cognitions, and avoidance; see
chapter 8), the therapist generates a list of between 10 and 20 situations
that evoke obsessional fear, which will be confronted during ERP ses-
sions. Situations that evoke rituals as noted on the patient’s self-monitor-
ing forms should also be considered for exposure. The Fear Hierarchy
Form, which appears in Fig. 10.1, provides space for recording hierarchy
items slated for situational (SIT) exposure. Some general considerations
for the hierarchy development process appear in Table 10.1 and are dis-
cussed next. Recommendations for generating hierarchies for fears char-
acteristic of each OCD symptom dimension appear later in this chapter.
Specificity. The specificity of hierarchy items is subject to the thera-

pist’s discretion. Although it is necessary to include items that match core
elements of the patient’s obsessional fears, it is not essential that the hierar-
chy include every potential fear cue or possible exposure variation. As an
example, consider the patient discussed earlier that feared injuring pedes-
trians with his automobile. In this case, driving might be a single hierarchy
item. Alternatively, this might be broken down into multiple items of var-
ied difficulty: driving on a deserted street, driving where pedestrians are
walking (e.g., a crowded parking lot), and driving where pedestrians are
232 CHAPTER 10
FIG. 10.1. Fear Hierarchy Form.
walking at night. Kozak and Foa (1997) suggested that it is best to develop
an initial hierarchy with enough detail to advise the patient (and therapist)
of the nature and difficulty of the exposure exercises, but general enough to
leave open the option to modify the specific task(s) in accord with the pa-
tient’s idiosyncratic concerns. This allows greater flexibility in developing
exposure tasks of varying degrees of difficulty if needed, some of which
might not be contrived until the particular exposure is begun.
TABLE 10.1
General Considerations for Preparing the Fear Hierarchy
In vivo exposure
• Specificity of hierarchy items should be at the therapist’s discretion.
• Each hierarchy item should have an identified rationale.
• Each hierarchy item should target a dysfunctional or catastrophic cognition.
• Consider exposure “field trips” for confrontation with stimuli outside of the office.
• Choose items that represent an acceptable level of risk.
• Begin exposure with moderately distressing items and progress to highly
distressing stimuli (i.e., graded exposure).
• The worst fear must be included in the hierarchy and scheduled for the mid-
dle of treatment.
Imaginal exposure
• Primary imaginal exposure—exposure to fear-evoking thoughts aided by
written or tape recorded material.
• Secondary imaginal exposure—visualizing feared consequences of not per-
forming rituals.
• Preliminary exposure—imagining the confrontation with feared stimuli be-
fore engaging in actual exposure.
To further illustrate, Susan described a fear of garbage cans, but said that
whereas some garbage cans posed little difficulty (e.g., those in offices),
others were extremely frightening (e.g., those in bathrooms and other pub-
lic places). Dumpsters were also completely avoided. Thus, garbage cans
was included as a hierarchy item, which allowed the therapist to help Su-
san begin with easier garbage cans and gradually work her way up to con-
fronting more difficult ones within the treatment session. This also
permitted the therapist to vary the way Susan confronted the garbage cans
according to her specific fear. Each new situation began with touching the
outside of the can, discarding an item, touching the inside, and then remov-
ing an item from the can. The specifics of conducting exposure sessions are
discussed in chapter 12.
Rationale. The patient and therapist must both understand how each
exposure task is designed to modify expectancies of danger. This ensures
that rather than something the therapist makes the patient do, each expo-
sure is a mutually agreed on undertaking. During the treatment planning
process, the reasons for selecting each hierarchy item should be made clear
to the patient as in the following example.
234 CHAPTER 10
Therapist: What is it about shaking people’s hands that is so distressing

for you?
Susan: I am worried that other people’s germs will contaminate me
and my family, and make us all sick.
Therapist: So, you either avoid hand shaking or you wash immediately
afterwards.
Susan: Right.
Therapist: I see. So, it sounds like a helpful exposure practice for you
would be to shake people’s hands and then touch your hus-
band and children.
Susan: But that’s crazy. I mean, I couldn’t do that.
Therapist: Well, I understand that it’s difficult for you to think about do-
ing that right now because you see it as very risky. But re-
member that one of the goals of exposure is to help you learn
that the probability of your fears coming true is much lower
than you think. By doing exercises like this you will learn that
you don’t need to fear shaking hands. By refraining from
ritualizing you will also learn that you don’t need to spend so
much time doing cleaning rituals because they’re unneces-
sary. Do you see what I mean?
Susan: Well, that will be a tough one, but I need to get over this
problem.
Targeting Cognitions. As the preceding exchange illustrates, hierar-

chy items should be chosen with one or more particular dysfunctional be-
liefs or catastrophic misinterpretations in mind. In this case the belief was
Susan’s overestimation of the threat of illness from contact with other peo-
ple’s hands. Therapists should think of exposures as experiments in which
patients test their catastrophic beliefs and assumptions as if they were ex-
perimental hypotheses. This again highlights the importance of assessing
patients’ feared consequences of exposure and of not performing rituals.
Feared consequences that involve the possibility of disasters in the distant
future (e.g., “I will get cancer in 40 years,” or “I will go to hell when I die”) are
not subject to immediate disconfirmation via exposure because it is impossible
to be 100% certain of whether such events will occur. Yet, people with such
fears fruitlessly seek to reduce the probability of feared disasters and gain as-
surances of safety with their safety-seeking behaviors. In these instances, the
patient’s problem is how he or she responds to doubt and uncertainty, not that
the feared disasters could one day occur (indeed they could). Thus, exposure
should focus on evoking uncertainty so that the patient can learn to better
manage such doubts.
Pushing the Envelope: Where to Draw the Line? Although people

with OCD grossly overestimate the probability and severity of potential danger
associated with their obsessions, the situations they fear often hold some ele-
ment of risk. This raises the issue of where to draw the line in exposing patients
to “risky” situations. As a general rule of thumb, situations should be chosen
that represent “acceptable levels of risk” within the confines of the therapist’s (or
an expert’s) judgment (Steketee, 1993). For example, the risks associated with in-
cidental contact with urine are sufficiently low that the therapeutic benefits of
putting a few drops on the skin outweighs the risk of harm to someone fearful of
becoming ill in this way (in fact, most urine is sterile). Conversely, immersing
one’s hand in a dirty toilet would be unnecessarily excessive. Scrupulous obses-
sions represent another level of concern and later in this chapter I address the
delicate issue of how far to urge patients toward completing exposures in which
they must act unscrupulously (e.g., by breaking religious laws).
When therapists I am working with become concerned that a particular
hierarchy item is too dangerous for exposure therapy, I suggest they ask
themselves the following question: Are there ways in which people without
OCD inadvertently perform this exposure (perhaps without even realizing
it)? As a general rule, if the answer is “yes,” then the exposure is probably
safe. Consider, for example, that many people do not wash their hands after
activities such as handling money, using the bathroom, picking up items that
have fallen on the floor, and casually making contact with garbage cans.
Stepping in dog feces is common. People also leave appliances plugged in
and lights and ovens on for hours at a time. It is even routine to leave appli-
ances such as computers and furnaces running for lengthy periods when no
one is home. Similarly, errors in paperwork, accidentally dropping poten-
tially harmful items such as pins or thumbtacks, using knives, and encoun-
ters with “unlucky” numbers (e.g., 13 and 666) occur routinely in day-to-day
life. Thus, purposeful confrontation with such situations is very instructive
for patients who feel they must go to great lengths to reduce the potential
risks associated with such things. In contrast, people do not eat pest control
products, leave their doors unlocked overnight, leave very young children
unattended with dangerous items, or purposely smear dog feces on their
clothing; so these would be inappropriate exposure tasks.
Incorporating the Worst Fear. Although research suggests the order in

which hierarchy items are confronted does not influence treatment outcome
(Hodgson et al., 1972), from a purely practical standpoint patients are most
receptive to initially approaching less threatening items and progressing
gradually to more disturbing ones (i.e., graded exposure). Importantly, situa-
tions or stimuli that evoke the patient’s worst obsessional fears must be in-
cluded on the hierarchy and confronted during therapy. Failure to do so
leaves critical dysfunctional cognitions firmly entrenched; for example, the
belief that some obsessional fears really are extremely dangerous and should
be avoided. To explain to patients the importance of confronting highly dis-
tressing situations, we often use the metaphor that in therapy “we must bull-
doze OCD over, or else, like weeds in a garden, the symptoms will grow
back.” Most patients understand this and, although they may initially resist,
236 CHAPTER 10
can usually be encouraged to keep an open mind. It might also be useful to

point out that for most patients, success with less frightening exposures often
makes the more anxiety-evoking situations much less difficult.
Using the Subjective Units of Discomfort Scale
Once an initial list of exposure situations and stimuli has been gener-
ated, a scaling system called the Subjective Units of Discomfort Scale
(SUDS) is applied. The patient assigns a SUDS score to each item on the Fear
Hierarchy Form so that the items can be ranked according to how much
subjective distress the patient anticipates during exposure. The therapist
can introduce this concept using Handout 10.1 as follows:
Therapist: Now that we have a list of exposure situations, the next step is to
rank the situations according to how much anxiety they would
evoke. To do this, we will use the SUDS scale—SUDS stands for
subjective units of discomfort [therapist gives the patient Hand-
out 10.1 or draws a similar scale on the whiteboard]. As you can
see, the SUDS goes from 0 to 100 and it helps you tell me how
anxious you feel. It is your own personal interpretation of your
anxiety. If your SUDS level is 0, then you are not anxious at
all—like you’re asleep. If your SUDS is about 20 or 30, it means
you have a mild degree of anxiety or distress. If your SUDS is 50,
you are moderately distressed. A rating of 70 to 80 SUDS means
a high degree of distress. And 100 SUDS is like experiencing the
worst possible anxiety you could think of—like you are tied to
the railroad tracks and the train is coming around the bend.
Usually when people have a high SUDS rating they also experi-
ence physical reactions like a pounding heart, shortness of
breath, sweating, or feelings of dizziness.
Handout 10.1. Introduction to SUDS.

The therapist should help the patient calibrate his or her SUDS ratings by
giving and asking for examples.
Therapist: It might take a little practice to get the hang of SUDS ratings.
Don’t worry if at first it feels like you aren’t doing it right—
it’s meant to be your own personal rating system. So, a 65 for
you is different than a 65 for someone else.
Right now, my SUDS is about 15. Overall I feel relaxed,
yet I know some of the things we are discussing are proba-
bly making you feel anxious. Tomorrow, however, I have to
give a lecture to a large group of students. When I think
about doing that, my SUDS goes up to about 30 because I’m
a little uneasy about speaking to large groups of people
that I don’t know. How about you? What is your SUDS
right now? What kinds of situations might make that
higher or lower?
At any point, if necessary, the therapist should help the patient make
adjustments in SUDS by pointing out when numerical ratings do not seem
to correlate with other variables (e.g., “You don’t look as anxious as I
would expect you to look with a SUDS of 80. I wonder if you are overesti-
mating your SUDS”). Once the patient is able to provide reliable and valid
SUDS ratings, the situations and stimuli on the exposure hierarchy are
ranked. Susan’s therapist initiated this process as shown here:
Therapist: Now, I’d like you to give each item on the hierarchy a SUDS
rating so we can see which situations are more and less dis-
tressing for you. Let’s start with touching public surfaces
such as pay phones, railings, elevator buttons, and door han-
dles. What would your SUDS be if you were to touch these
things and not wash your hands afterward.
Susan: That would make me fairly anxious. I guess my SUDS would
be about 50.
Therapist: Good. How about using a public bathroom, like the faculty
restroom at your school?
Susan: And I couldn’t wash afterwards, right?
Therapist: Right. You’d have to go without washing; so you’d be feeling
contaminated.
Susan: That would make me very, very anxious. I feel my heart rac-
ing just thinking about it. So, I guess my SUDS would be
about an 85.
Therapist: Good job. How about if you had to hand out graded papers to
your students without rechecking for any mistakes?
Susan: That would be a little easier—like about 65.
238 CHAPTER 10
Imaginal Exposure
Why Imaginal Exposure?
Recall that for individuals with OCD, fear is evoked not only by environ-
mental triggers such as bathrooms and knives, but also by internal stimuli
such as intrusive thoughts, impulses, doubts, and images. Whereas situa-
tional exposure is designed to reduce fearful responses to external situations
and stimuli, the aim of imaginal exposure is to foster habituation to fear-
evoking obsessional thoughts, and to help patients correct how they misin-
terpret the presence and significance of such thoughts. To illustrate, consider
the case of Jill, who was obsessed with the idea that she might mistakenly
poison her family’s food with lye-based household cleaning agents. To en-
sure against any harm, Jill kept all poisonous substances locked in a base-
ment closet. Although she frequently checked that the closet remained
locked, Jill continued to have upsetting thoughts and doubts about whether
her family was truly safe from what she believed were her “unconscious evil
tendencies.” To reduce her doubts, Jill ritualistically asked her relatives for
assurance that they were feeling OK. Treatment included situational expo-
sures in which Jill prepared food for her family in the presence of open bottles
of cleaning solution. For imaginal exposure, she purposely visualized a
scene in which she had mistakenly poisoned her family because she was not
careful enough about toxic materials. Repetition of the scene continued, and
Jill refrained from seeking reassurance, until her anxiety habituated.
In contrast to situational fear cues, which are often concrete, internal fear
cues are covert and highly elusive, and therefore can be precarious targets for
exposure. Although in vivo exposure often implicitly evokes obsessional
thoughts, imaginal exposure provides a more systematic approach for ex-
posing the patient to the key fear-evoking elements of his or her obsessions.
The recommended methods for conducting imaginal exposure include (a)
using audiocassette tapes (endless loop tapes work especially well) or (b)
written scripts containing the anxiety-evoking material (Freeston &
Ladouceur, 1999). Both of these media allow the therapist to prolong the pa-
tient’s confrontation with an otherwise intangible stimulus and, if necessary,
manipulate its content. Moreover, the repetition of fear-evoking material
(i.e., via loop tape) is incompatible with engaging in mental rituals or covert
neutralization; thus it assists with response prevention. The use of an audio-
tape further ensures that self-supervised (homework) exposure will incorpo-
rate confrontation with the correct stimuli.
Types of Imaginal Exposure
Imaginal exposure is an essential treatment component for most, but not

all, individuals with OCD. However, this technique may be used in three
different ways depending on the specifics of the patient’s symptoms (the

techniques are illustrated later).
• Primary imaginal exposure is essentially situational exposure to un-
wanted thoughts. It involves directly confronting repugnant
thoughts, images, and urges (i.e., violent, sexual, or blasphemous ob-
sessions) via methods such as loop tapes. If situational triggers do not
evoke these obsessions, primary imaginal exposure might be the only
available means of direct exposure to these mental stimuli.
• Secondary imaginal exposure is used to augment situational exposure
when confrontation with actual situations evokes fears of disastrous
consequences (e.g., in Jill’s case described earlier). In such instances,
imaginal exposure is begun during or after situational exposure, and
should involve visualizing the feared outcomes or focusing on uncer-
tainty associated with the risk of feared outcomes.
• Preliminary imaginal exposure entails imagining confronting a feared
stimulus as a preliminary step in preparing for situational exposures.
For example, a patient might vividly imagine touching the bathroom
floor before actually engaging in situational exposure to the bath-
room floor.
Susan’s therapist gave the following introduction to imaginal exposure:
Therapist: I mentioned that in addition to practicing exposure to real-

life situations, we would conduct exposure in imagination.
Imagery exposure is used to reduce fear associated with cer-
tain thoughts, such as your unwanted thoughts of harming
your daughter. The process is very similar to situational ex-
posure in that you will practice thinking the anxiety-provok-
ing thoughts over and over, and without ritualizing, until
your distress reduces on its own. Eventually you will find
that you can think the obsessional thought without experi-
encing so much distress. We will do imaginal exposure using
endless loop tapes. That is, we will make recordings of the
anxiety-evoking thoughts and then you will practice listen-
ing to the tape until habituation of anxiety occurs.
Imaginal Exposure and the Fear Hierarchy
Scenes and scenarios for imaginal exposure are chosen from the list of ob-
sessional thoughts and feared consequences generated during assessment
and information gathering (see chapter 8). Brief descriptions of these scenes
are entered onto the Fear Hierarchy Form (IMAG) along with the correspond-
ing situational exposures where applicable. For example, a situational expo-
240 CHAPTER 10
sure to driving at night might be followed by a corresponding imaginal

exposure to doubts about possibly having hit a pedestrian. Because the
imaginal exposure stimuli also must match the patient’s fear, it is important for
the therapist to know the specific cognitive elements the patient finds distress-
ing; for example, the idea that “the police are probably looking for me,” and
how “my family will be terribly upset when they learn that I killed someone.”
Primary Imaginal Exposure. Primary imaginal exposure items

might have their own place on the fear hierarchy, especially if the particu-
lar thought will not be addressed with situational exposure. Items will in-
clude articulations of the distressing thought, such as an explicit narrative
of an unacceptable sexual encounter, description of a horrible accident, or
repetition of an upsetting phrase. The thoughts can be articulated in writ-
ten form or verbally recorded onto an audiotape (i.e., loop tape). The ther-
apist and patient should outline the content of each imaginal item before
beginning each exposure so that both are aware of the desired content and
expected distress level.
The following example illustrates a primary imaginal exposure for a
man with unacceptable homosexual obsessions. When conducting loop
tape exposures, it is up to the therapist to decide whose voice is heard on the
tape (therapist or patient). This particular patient remarked that hearing
himself verbalize the obsessional thought would evoke more anxiety than
listening to the therapist’s voice. Therefore, after the following text was col-
laboratively drafted and edited, the patient read it aloud (in an appropri-
ately funereal tone) into the tape recorder.
I am in the locker room at gym after a long hard workout. I decide to take a
shower even though I am afraid that I will see other men in the nude. There
are several other guys in the locker room in various states of undress. I can
see their butts as they bend over, and I can see their penises. I look at their
bodies and find myself admiring their muscles and the size of their penises.
Then I feel the urge to kiss one of them and to touch him. I don’t know if this
means I am gay or not. I think about what it would feel like to kiss another
man and touch his penis. Instead of trying to push the thought away, I let it
just stay in my mind. He is a young, muscular guy, about my height. I think
about his pubic hair and what his penis must look like when it is erect. It is
probably very long and has a large circumference. I think about kissing it
and putting it in my mouth …
Patients’ apprehension over merely uttering their seemingly horrific,

immoral, or obscene obsessional thoughts can interfere with the planning
of imaginal exposure (the concealment of obsessions is discussed in previ-
ous chapters). However, this is equivalent to avoidance and will prevent
the therapist from being able to match the exposure stimuli to the patient’s
actual fear. To manage concealment, the therapist should assess how pa-
tients are interpreting their obsessional thought that leads them to feel they
cannot describe it out loud. Next, cognitive techniques can be used to help
the patient think differently about the obsession (i.e., normalizing). The
therapist should also empathetically reiterate that the purpose of treatment
is to help the patient confront, rather than avoid, feared thoughts.
On a related note, therapists should be aware that obsessional thoughts
can be extremely offensive, unsettling, and graphic. It behooves one to pre-
pare for this and to regulate his or her response to hearing a patient describe
these intrusions. Recognize that the patient probably harbors the concern
that “even the therapist will be ‘freaked out’ by my horrible thoughts.”
Thus, even a hint of alarm, horror, or disgust on the part of the therapist
could reinforce such maladaptive beliefs. The appropriate response to an
admittedly repugnant obsession is to acknowledge in a nonjudgmental
way that it is understandable how the patient could assume that such a
thought is significant, but that nevertheless, even highly disturbing intru-
sive thoughts are neither harmful nor especially important. The therapist
might even take the opportunity to one-up the patient by describing one of
his or her own distressing intrusions. As a final point, there is no evidence
that repeated exposure to patients’ descriptions of their horrific thoughts
causes traumatization to either the patient or the therapist, as has been
espoused by some in the traumatic stress studies field (e.g., Stamm, 1999).
Secondary Imaginal Exposure. Secondary imaginal exposures are

conducted in conjunction with the corresponding situational exposures.
Here, the most practical way of presenting the fear-evoking material is via a
scripted narrative, spoken by the patient or therapist. As described previ-
ously, the narrative contains the most distressing feared consequences as-
sociated with situational exposure (and failure to perform safety
behaviors). It should be presented in the aftermath of situational exposure
to the corresponding external trigger. An example of a secondary imaginal
exposure scene for a patient with fears of unlucky numbers and prayer ritu-
als is presented here. The patient, whose dysfunctional beliefs included an
inflated sense of responsibility for preventing harm, had just completed sit-
uational exposure to the number 13:
You are thinking about how you have exposed yourself to the number 13 to-
day. You wrote “13” over and over on a piece of paper, on the whiteboard in
my office, and you even wrote it on your hand and on the back of your father’s
picture. You have never dared to do such things because you think it will
bring bad luck. Now, you wish you could pray to God to prevent bad things
from happening to your father. But you know that for treatment to work, you
must refrain from praying. So, you don’t allow yourself to pray. Just then, the
phone rings. It is your sister calling from the hospital. She is crying and is
barely able to tell you that Dad has just been killed in a terrible car crash. A
large truck that ran through a red light hit his compact car. He didn’t stand a
chance. You tell yourself that it’s your fault. You know why Dad is dead. If
only you hadn’t acted so irresponsibly with the number 13. If only you’d
prayed. Now Dad is gone and you could have prevented it.
242 CHAPTER 10
Preliminary Imaginal Exposure. In most cases, preliminary imaginal

exposures are not specifically proposed during the treatment planning
phase. Instead, they are used as needed when conducting situational expo-
sure. For example, if a patient is extremely anxious about walking through
tall grass for fear of stepping in dog feces, he or she might agree to imagine
doing this as a precursor to the actual exercise. Importantly, studies indicate
that all things being equal, situational exposure is more potent than
imaginal exposure for reducing fears of external obsessional triggers (e.g.,
Rabavilas et al., 1976). Thus, preliminary imaginal exposure should be un-
dertaken with the patient’s understanding that actual exposure will follow.
EXPOSURE STIMULI FOR DIFFERENT

SYMPTOM DIMENSIONS
We now turn to a discussion of the issues involved with developing fear hi-
erarchies and arranging exposure exercises for each of the OCD symptom
dimensions. The actual implementation of exposure procedures is de-
scribed in chapter 12.
Harming
Exposure for harming symptoms must entail (a) confronting situations in
which the patient fears that he or she will be responsible for harm, and (b)
imagining the feared consequences. For Susan’s fear of assigning incorrect
grades, the therapist suggested exposures involving grading papers
quickly, recording the grades hastily, and returning the assignments with-
out compulsively checking for accuracy; then imaginally confronting
doubts about mistakes and thoughts that her carelessness might have cost
some students successful careers. From the behavioral perspective, such
exposures promote habituation to feared situations and doubts about
feared disastrous outcomes. From a cognitive point of view, these tech-
niques modify overestimates of threat and responsibility, as well as the in-
tolerance of uncertainty. Patients learn that their feared consequences are
unlikely enough that they need not be concerned that the absence of an ab-
solute guarantee indicates a strong probability of disaster. The imaginal ex-
posure component also serves to modify beliefs about the importance of
thoughts. Informal cognitive interventions can be incorporated into expo-
sure sessions to facilitate the correction of faulty cognitions.
Additional examples of exposure exercises for patients with harming ob-
sessions include the following: If patients are afraid of fires, exposure can in-
volve leaving lights and appliances on while leaving the home. Switches or
knobs can be turned off rapidly and without checking. If the fear of burglary is
present, the patient can lock the door in a “careless” way and leave home
quickly without double-checking. Fears that one will cause bad luck can be ad-
dressed by having the patient do whatever he or she fears might cause bad
luck; for example, writing phrases such as “I wish Mom would get cancer.” If
patients are afraid of harming pedestrians or causing traffic accidents, they can
drive in crowded places (e.g., parking lots) without checking the rearview mir-
ror. If patients are concerned about being distracted while they drive, the radio
volume can be turned up. For fears of causing injury in other ways, situational
exposure might involve placing items such as glass or pins on the ground or
handling sharp objects in the presence of others. Obsessions about making
mistakes with paperwork can be confronted by working very quickly without
rechecking for accuracy (perhaps with distractions as well). Fears of mistak-
enly discarding items (e.g., notes, money) can be addressed by throwing away
trash without carefully checking. Each of these situational exposures should
be followed by secondary imaginal exposure to being responsible for the
feared consequences (or not knowing for sure whether the consequences will
occur). This prolongs the exposure, facilitates habituation to the feeling of un-
certainty, and helps the patient learn that he or she can manage uncertainty.
An exemplary fear hierarchy for Kristi, a patient who feared she might
blurt out insults and obscenities (or write them in letters and e-mails) at in-
opportune times (e.g., when speaking with her boss), is presented below.
Kristi’s therapist arranged in vivo exposure to different situations that
Kristi was afraid might lead her to use curse words. Imaginal exposures in-
volved thinking about the feared consequences of these situations.
• (Situational) Think the word bastard while talking with the therapist
(45 SUDS).
• (Situational) Think the word bastard while writing e-mail or letters to
friends (55).
• (Imaginal) What if I wrote bastard by mistake and will lose my friends
(60)?
• (Situational) Think the word shithead while sending e-mail to the boss
(70).
• (Imaginal) What if I accidentally wrote shithead, boss is offended, I
lose my job (75)?
• (Situational) Type the word shithead before typing e-mail to the boss
(80).
• (Imaginal) What if I typed shithead in the wrong place by mistake, boss
is offended, I get fired (85)?
Before moving on, let us consider some practical tips regarding expo-
sures for harming symptoms. First, the therapist’s presence sometimes in-
validates exposure because the patient can easily transfer responsibility for
any negative outcomes onto the therapist (e.g., “The therapist wouldn’t let
anything terrible happen”). If this is the case (and patients should be asked
about this directly), the exposure must be performed without close supervi-
sion. For example, In Kristi’s case, the therapist left the room so that she
244 CHAPTER 10
could not see what Kristi wrote or typed. This ensured that Kristi would
learn that the only explanation for her failure to write curse words was that
thinking curse words does not directly cause one to write them. Second,
many situational exposures for harming concerns are brief and exclude the
repetition of the same task within a single session. For example, locking the
door and leaving the house takes only a few seconds and repeating this ac-
tivity (or prolonging it) would essentially be checking and attaining reas-
surance that the door is locked. Thus, instead of repeating such exercises
multiple times during the session, the situational exposure is followed by
procedures to help the patient confront obsessional thoughts and uncer-
tainty associated with not checking (recall that intolerance of uncertainty is
a primary cognitive feature of this symptom dimension). Imaginal
exposure to the feared consequences is the best way to accomplish this goal.
Finally, for patients with fears of harm that could occur in the distant fu-
ture, exposure exercises should be designed to weaken associations be-
tween uncertainty and high levels of anxiety. In vivo exercises can
incorporate situations that arouse feelings of uncertainty, and imaginal ex-
posure should focus on not knowing for sure whether the feared conse-
quence will happen (Abramowitz, 2001). From the behavioral perspective,
such exercises facilitate habituation to feelings of uncertainty. From the
cognitive point of view, such exercises “decatastrophize” uncertainty and
help patients to better manage obsessional doubt.
Contamination
Exposures for this subtype must include confrontation with feared con-
taminants that evoke avoidance or urges to perform decontamination rit-
uals. Recall the discussion of primary and secondary sources of
contamination in previous chapters. Whereas direct exposure to the pri-
mary source of contamination is usually essential, confronting every sec-
ondary source may not be necessary. The patient and therapist should
agree to practice with those stimuli that are associated with functional im-
pairment. Common exposure stimuli include floors, toilets, hospitals,
public surfaces (e.g., elevator buttons, waiting room chairs, sink or
shower faucets), body parts (e.g., anus), bodily fluids (e.g., urine), chemi-
cals (e.g., pesticides), certain people (e.g., homosexuals), and specific
places (e.g., cemeteries). Some patients have highly idiosyncratic fears of
contamination from certain clothes, geographic locations (e.g., Canada),
or colors (e.g., red), which might represent earlier events or relationships
that are distressing (e.g., there was an outbreak of SARS in Canada). Dur-
ing exposure, patients must learn that contamination is ubiquitous.
Therefore they should become thoroughly immersed in the feared stimu-
lus. If patients try to avoid contaminating special items (e.g., favorite
keepsakes), people (one’s children), or places (e.g., certain rooms), expo-

sure must entail tainting these things as well. If obsessional ideas or im-
ages of germs or illness are prominent or are misappraised as very
significant, secondary imaginal exposure to such mental stimuli should
accompany situational exposures. Next I present a typical fear hierarchy
for a patient with contamination fears. The patient in this example, Jim,
was fearful of contamination from dog feces.
• (Situational) Newspaper from front lawn (35 SUDS).

• (Imaginal) Feces might have been on lawn, and now might spread all
over the apartment.
• (Situational) Shoes (45).
• (Imaginal) Might have stepped in dog feces without realizing it (60).
• (Situational) Walk in park where dogs go to the bathroom (65).
• (Situational) Step in dog feces and wipe off with tissue (75).
• (Imaginal) I am contaminated with germs from feces (75).
• (Situation) Walk in others’ homes with shoes that had been in the park
(80).
• (Imaginal) What if I make others sick from feces germs (80).
• (Situational) Contaminate self, car, and apartment with shoes from
the park (95).
From a behavioral perspective, contamination exposures cultivate ha-

bituation to feared contaminants and weaken anxiety responses associated
with such stimuli. From a cognitive standpoint, these exercises might ad-
dress a number of faulty cognitions. If patients have fears of illnesses that
will ensue if exposure is not terminated by washing or cleaning, exposure
corrects overestimates of the threat of illness. If there is a fear of contaminat-
ing others and making them ill, exposure also addresses the inflated sense
of responsibility. For patients with no specific fears of illnesses, exposure
targets the intolerance of imperfection and anxiety so that they learn that
affective discomfort does not persist indefinitely.
As discussed previously, patients’ fears occasionally necessitate expo-
sure to things that can pose actual danger or that evoke disgust for most
people. Examples include chemical pesticides and bodily fluids or wastes.
When it comes to such contaminants, people with OCD usually fear that
they might have been exposed, and their decontamination rituals are there-
fore designed to remove such contaminants just in case (this is the intoler-
ance of uncertainty component). Therefore, exposure need not involve
bathing in pesticides or putting one’s hand in a dirty toilet. Evoking the
sense of uncertainty is often sufficient (e.g., when walking in the park, you
might have stepped in dog feces). Some suggestions for how to expose pa-
tients to such items follow: For the fear of pesticides, the patient can visit a
246 CHAPTER 10
hardware store, touch bottles of pesticides, and practice applying the chem-
ical as directed on the label (without taking extra precautions). For fears of
feces (as in Jim’s case earlier), harmless spots or stains can be obtained on a
paper towel, which may be carried around in the patient’s pocket or used to
contaminate other “safe” areas.
Incompleteness
Situational exposure tasks for patients with this presentation of OCD will
be those that evoke discomfort associated with imbalance, disorder, and
asymmetry (i.e., NJREs). Hierarchy items often need to be highly patient
specific, but might include the following: tilting pictures unevenly; putting
items in the “wrong” place or arranging them asymmetrically; using poor
handwriting; arranging bookshelves or drawers out of order; and putting
smudges on tables, windows, or the computer screen. For patients with ob-
sessions with certain lucky numbers, the “wrong” number can be chosen
wherever possible, counting can be done out of order, to the “wrong” num-
ber, or routine activities performed the “wrong” number of times. For those
with the need for left–right balance, left–right asymmetry can be achieved
by physical (e.g., brushing against the right side only) or visual means (e.g.,
look only at the right side). For some patients, it will be important that expo-
sure be consistent. Thus, for example, desks at home and at work must be
rearranged, and friends or relatives may be enlisted to help with such tasks.
Imaginal exposure is typically not used for patients with incompleteness
symptoms who fear only that their distress will persist indefinitely. How-
ever, as with exposure for harming symptoms, if the not just right feeling is
associated with magical thinking concerning responsibility for harm (e.g.,
“I must put my shoes on in the right order or else my father will die”), sec-
ondary imaginal exposure to such disasters should be incorporated. So,
from a behavioral standpoint, exposure for this symptom dimension fos-
ters habituation to feeling uncertain or not just right. From the cognitive
perspective, such exercises modify beliefs about the intolerability of dis-
tress, NJREs, and uncertainty. An example of a fear hierarchy for Tiffany,
who had incompleteness symptoms, is provided here.
• (Situational) Place books out of order on the bookshelf (45 SUDS).

• (Situational) Leave the bed unmade (50).
• (Situational) Write a note to boyfriend with sloppy handwriting (55).
• (Situational) Tilt the pictures on office and bedroom walls (55).
• (Situational) Write bank checks with “sloppy” handwriting (55).
• (Situational) Leave the dresser drawers and closets with clothes “out
of order” (60).
• (Situational) write work memos and forms with “sloppy” handwrit-
ing (80).
Unacceptable Thoughts
It is helpful for therapists to think of this symptom dimension as a phobia of

thoughts. Thus, the fear hierarchy must incorporate primary imaginal ex-
posures in which the patient repeatedly thinks the unacceptable intrusive
obsessional thoughts (ideas, images, impulses), as well as in vivo exposure
to any key situations and stimuli that evoke such obsessions. For example,
an individual afraid of losing control and acting on impulse should be ex-
posed to the situation in which the impulse occurs. If the unwanted urge to
yell curse words is evoked by attending religious services, the patient
should attend a religious service and experience the urge without engaging
in avoidance or any safety behaviors. The aim of this exercise is not to de-
sensitize patients to the idea of acting inappropriately. Instead, this particu-
lar exposure would help the sufferer learn that thinking about acting
inappropriately is not what causes inappropriate behavior, and therefore,
avoidance and safety behaviors are unnecessary.
As I have discussed earlier, written narratives and loop tapes describing
anxiety-evoking scenes are the best methods of systematically exposing pa-
tients to their feared thoughts. From the behavioral point of view, exposure
exercises for unacceptable thoughts promote habituation to these un-
wanted disturbing intrusions and extinguish classically conditioned fear.
From the cognitive point of view, this type of ERP modifies erroneous be-
liefs about the importance of, and need to control, unwanted thoughts (e.g.,
TAF), as well as overestimates of threat and responsibility. Imaginal expo-
sures for violent obsessions will be highly idiosyncratic and based on the
patient’s specific unacceptable thoughts. Examples include describing im-
ages of stabbing loved ones and thoughts of children dying. Situational ex-
posures could include handling potential weapons (perhaps beside a
sleeping baby or spouse), standing on a subway platform, watching the
news, viewing violent movies, reading books about violence, or saying and
writing words associated with violence (e.g., murder, stab), or whatever
triggers the unwanted idea, image, or urge.
For patients with unacceptable thoughts or doubts regarding homosex-
uality, imaginal exposure might include confronting images of oneself en-
gaged in homosexual behavior or thoughts that evoke uncertainty over
sexual preference (e.g., “Maybe the rush you felt when you were in the gym
locker room was really a sign of latent homosexuality”). In vivo exposure
might involve viewing homoerotic stimuli (e.g., gay literature or pornogra-
phy), visiting gym locker rooms or gay bars, and words such as gay or les-
bian (which might entail writing the word repeatedly on a piece of paper
and keeping the paper in a pocket or wallet). Similarly, for someone with
unwanted sexual thoughts about children or incest, imaginal exposure
should involve thoughts of such activities. Ideas for situational exposure
include watching children on playgrounds; seeing one’s child naked;
248 CHAPTER 10
glancing at relatives’ crotches or looking at pictures and focusing on these

areas; and words such as molest, pedophile, and incest. An example fear hier-
archy for Danielle, who suffered with unacceptable violent obsessions
about harming her newborn baby, is presented here.
• (Situational) Burp the baby after giving him a bottle (45 SUDS).
• (Imaginal) Ideas of beating the baby very hard on his back (50).
• (Situational ) Hold baby while near a flight of stairs (50).
• (Imaginal) Images of throwing the baby down the stairs (75).
• (Situational) Take the baby to the train station and stand on the plat-
form (65).
• (Imaginal) Images of throwing the baby in front of an approaching
train (85).
• (Situational) Give the baby a bath (80).
• (Imaginal) Thoughts of drowning the baby in the tub (85).
• (Imaginal) Images of shaking the baby very hard.
• (Imaginal) Images of the baby lying dead in her crib.
• (Situational) Using a knife while the baby is nearby.
• (Imaginal) Thoughts of stabbing the baby.
• (Situational) Hold blunt end of knife to the baby’s skin.
• (Imaginal) Thoughts of stabbing the baby.
One patient who was evaluated and treated in our clinic described a less
common presentation of unacceptable thoughts. His main fear was that the
mere presence of senseless intrusive thoughts (many of which he appraised
as unacceptable and therefore took great pains to try to control) indicated
that he had a serious cognitive deficit. He spent hours on end fighting his
(normal) senseless thoughts, trying to figure out why these thoughts were
occurring and what they meant about his cognitive functioning. He even
noticed that he was having difficulty attending to conversations and read-
ing material (likely due to the fact that he was deploying inordinate atten-
tion to battling intrusive thoughts), and was convinced this was evidence of
a serious cognitive dysfunction. It was somewhat difficult to arrange an ex-
posure hierarchy for this individual because there were few particular re-
curring intrusions—distress could literally be evoked by any unwanted or
senseless cognitive intrusion (e.g., images of people he did not like, “Could
I be cloned?”). The only consistently recurrent obsessional intrusion was
the doubt about his cognitive well-being. Thus, cognitive techniques were
used to help him correct how he was interpreting his senseless thoughts,
and imaginal exposure involved purposely evoking doubts and
uncertainty about whether he had a serious cognitive disorder.
Religious obsessions present challenges to the hierarchy development
process because patients with such symptoms often believe they have com-
mitted sins (and will suffer serious consequences) when, in fact, they have
not. Moreover, the patient’s religious and social environment reinforces such
beliefs, at least on an intermittent basis. Exposure items for such obsessions,
which can often be derived directly from avoidance patterns and descrip-
tions of anxiety-evoking stimuli, involve deliberately engaging in behavior
(including thinking unacceptable thoughts) that the patient perceives as
blasphemous or immoral, but which are not necessarily condemned by reli-
gious authorities. For example, a person who is afraid of experiencing blas-
phemous thoughts while reading the Bible should read the Bible for
situational exposure. Other examples of possible exposures include houses
of worship, books about atheism, and other religious icons that evoke un-
wanted intrusions. Potential imaginal exposures include images of Jesus
masturbating on the cross, doubts about God’s existence, and ideas of dese-
crating religious artifacts or places of worship. The nature of these tasks re-
quires that the rationale for ERP be clearly explicated to the patient. If this is
misunderstood, or the therapist is perceived as insensitive, the patient may
view therapy as an assault on his or her religion. Some suggestions for help-
ing patients with religious obsessions (i.e., scrupulosity) embrace ERP are
provided in the text that follows.
Patients with religious obsessions often hold catastrophic views of God
and sin that are inconsistent with even their own religious doctrine
(Abramowitz, Huppert, et al., 2002). Whereas most modern religions
teach that God loves all people unconditionally and that one may repent
for sins and be forgiven, those with religious obsessions often view God as
petulant, easily angered, and vengeful. Naturally, such beliefs lead to
practicing religion out of fear rather than out of love and faith. It is worth
pointing out this distinction to patients so that they may see how their ex-
tremely fearful view of God departs from what other members of their de-
nomination (e.g., family and clergy) believe. An important message is that
according to most religions, patients will not lose God’s love unless they
(a) intentionally decide to do things they know are evil (e.g., murder
someone) and (b) remain remorseless. Therefore, unwanted thoughts,
ideas, or images do not count as violations. The therapist can also point
out to believers that if God created the human mind, then God surely un-
derstands that people sometimes have thoughts that are contrary to their
true beliefs. The case should be made that doing ERP will help the patient
become a more faithful follower of his or her religion because it will help
him or her to trust God, rather than being fearful.
People with religious obsessions are often narrowly focused on trivial
violations of religious doctrine, often overlooking more important reli-
gious commandments (Greenberg, 1984). For example, one devout Catho-
lic patient was extremely fearful that he would be punished if his relatives
decided not go to Mass (Catholics are not to deliberately interfere with oth-
ers’ plans to go to Mass). However, he thought nothing of cursing at his par-
ents (a violation of the Fifth Commandment to honor thy mother and
250 CHAPTER 10
father) in his attempt to convince them to go. Moreover, his history of sam-
pling fruit and candy for sale at the grocery store when no one was looking,
and taking magazines from the dentist’s waiting room without asking
(Thou shalt not steal) did not seem to concern him. The patient benefited
from a discussion of his lack of concern with minor infractions, and learned
that the purpose of ERP was to teach him how to manage his obsessional
fears in a similar way.
Informing patients that for centuries, theologians have prescribed
strategies similar to ERP for people with religious obsessions is another
way to encourage individuals with such symptoms to undertake treat-
ment (Ciarrocchi, 1995). From a theological perspective, scrupulosity and
obsessional fear puts one in danger of sin by pride, self-will, and disobedi-
ence. The Jewish Talmud (written law) also considers religious acts per-
formed out of the fear of punishment to be antithetical (Sotah, 22b).
Training manuals for pastoral counselors recommend that people with
scrupulosity purposely act contrary to their scruples. Specific guidelines
include (a) emulating conscientious people even if doing so might violate
the rule in question, (b) allowing oneself to purposely evoke “impure”
thoughts, and (c) disavowing oneself of repetitive confessions and redun-
dant prayer (Jones & Aldeman, 1959). Note the similarities between these
guidelines and the components of CBT. Ciarrocchi’s (1995) self-help book
on scrupulosity presents an excellent discussion of this topic and is a use-
ful resource for helping strictly religious patients who are ambivalent
about beginning ERP.
As a last resort the patient may be permitted to consult with a religious
authority (e.g., a priest, rabbi, or pastor) regarding what is appropriate to
do for exposure. The hierarchy may then be assembled according to this
guidance. If at all possible, the therapist should see that such advice is ob-
tained from a more liberal authority as to avoid misunderstandings and re-
inforcement of the patient’s fears. It should also be agreed that the
authority’s suggestions (no matter how vague) would be followed without
the pursuit of further advice or second opinions (as this would constitute
reassurance seeking). If ERP can be conducted by relying on what religious
authorities have previously told the patient (i.e., without consultation
during treatment), this is ideal.
FINALIZING THE EXPOSURE PLAN
Scheduling Exposures
The final step in planning for exposure is deciding on when (i.e., which ses-
sion) each hierarchy item will be confronted. Typically, the therapist sug-
gests that exposure begin with moderately anxiety-provoking situations
(situations that produce only minimal anxiety do not provide therapeutic

benefit) and progress, in order of difficulty (i.e., SUDS level), to more dis-
tressing stimuli. Beginning with less difficult tasks increases the likelihood
of a successful initiation to exposure. This will raise the patient’s confidence
and motivate him or her to stay engaged during more difficult exercises. If
the patient reports that all hierarchy items evoke similar levels of distress, it
may be left up to the patient to decide on the order of items. Progression up
the hierarchy should occur as rapidly as possible so items with the highest
SUDS ratings can be confronted sooner rather than later, perhaps as early as
during the sixth exposure session (Kozak & Foa, 1997). Scheduling the most
distressing exposures for relatively early in treatment buys the therapist
more time to help the patient confront these difficult situations should in-
termediate steps be required. On the other hand, delaying exposure to the
worst fears until late in therapy reinforces the patient’s avoidance habits.
Worse, not confronting the worst fear at all during treatment sends the mes-
sage that such situations are dangerous and really should not be con-
fronted. Procrastination and avoidance undermine the aim of treatment
and are likely to lead to relapse because they propagate mistaken beliefs
about obsessional stimuli. After the greatest fear has been faced, treatment
sessions are used for extending exposure practice to multiple contexts (in-
cluding in the patient’s home). Susan’s initial exposure hierarchy, complete
with SUDS ratings and session assignments, appears in Fig. 10.2. Imple-
mentation of this treatment plan is described in chapter 12.
252 CHAPTER 10
FIG. 10.2. Susan T.’s fear hierarchy.

11
Treatment Planning II:
Response Prevention, Support,
and Clarification of the Plan
Chapter 10 described the procedures for explaining ERP and developing the
fear hierarchy. This chapter opens with a discussion of guidelines for forming
a response prevention plan. Specific techniques for stopping rituals across the
various OCD symptom dimensions are presented. Next, the chapter focuses
on how to help the patient’s family (or cohabitants) end their participation in
avoidance and rituals. Inclusion of one or more relatives or close friends in
therapy as support persons is suggested, especially if the therapist is con-
cerned that adherence to treatment is anticipated to be a problem. The chapter
ends with an illustration of how to summarize the treatment plan and review
what is expected of the patient during treatment. It is crucial that the patient,
therapist, and anyone else involved in the treatment program align together in
a collaborative effort to reduce the patient’s OCD symptoms.
RATIONALE FOR RESPONSE PREVENTION

Simply put, response prevention is the termination of all safety-seeking be-
havior performed in response to obsessional fear.1 This procedure prolongs
1
Some authors use the term ritual prevention to describe this procedure (e.g., Kozak & Foa,
1997). However, I prefer response prevention because it implies a broad (continued)
253
254 CHAPTER 11
exposure and ensures that habituation and cognitive change occur, and is
therefore a critically important component of therapy. To illustrate, if Su-
san T. took a 20-minute shower to decontaminate herself after situational
exposure to “garbage can germs,” her distress would immediately be re-
duced; however, she would prevent herself from learning that her distress
would have declined naturally anyway (i.e., habituation) even without
the shower ritual. In addition, she is likely to attribute the nonoccurrence
of an illness to the fact that she showered. This leaves unchanged her mis-
taken belief that garbage cans are dangerous (“If I had not showered, I
would have become ill from the trash can”). Similarly, if she completes a
prayer ritual each time she experiences unacceptable thoughts of harm to
her daughter, she will never learn that intrusive thoughts do not automat-
ically lead to taking action. Instead, she would continue to believe that
one must take precautions to prevent acting impulsively on unwanted vi-
olent thoughts. The rationale for response prevention should be expli-
cated during treatment planning and reiterated throughout the course of
therapy. Susan’s therapist introduced response prevention in the follow-
ing way:
Therapist: I said before that in addition to exposure, treatment will in-

volve practicing changing your patterns of responding to ob-
sessional fear. To do this it will be important for you to stop
the habits you have been using, such as compulsive rituals,
mental rituals, and attempts to suppress and neutralize up-
setting thoughts. Collectively, we call these habits rituals or
safety behaviors, because you do them to make yourself feel
safer when you have obsessional thoughts about danger.
Practicing stopping rituals and other safety behaviors is
called response prevention, and there are three reasons why
this is an important part of treatment. First, it will help you
learn that your anxiety declines even if you remain exposed
to your fears. Second, it will teach you that your rituals are
unnecessary and that you don’t need to do them to reduce ob-
sessional fear or prevent disasters. That’s because the things
you are afraid of are unlikely to happen whether or not you
ritualize. However, the only way you can learn this is by not
ritualizing and observing what happens. Finally, by not
ritualizing, you allow yourself to learn better strategies for
coping with obsessional fear. Each time you ritualize, you
1
(continued) cessation of all safety-seeking responses to obsessional fear (i.e., avoidance,
neutralization, rituals, reassurance seeking), whereas ritual prevention implies that only com-
pulsive rituals are to be terminated.
TREATMENT PLANNING II 255
strengthen your OCD patterns of using avoidance for dealing

with obsessional distress. By resisting your rituals, you will
develop healthy thinking and behavior patterns that won’t
interfere with your life or cost you so much time and energy.
DESIGNING THE RESPONSE PREVENTION PLAN
General Considerations
Preparation for response prevention parallels the planning of exposure

tasks. The patient’s compulsive rituals, subtle neutralizing strategies, and
covert attempts to seek reassurance are described in detail and targeted for
cessation. The optimal strategy is complete abstinence from all safety be-
haviors; however, some patients will require a gradual approach in which
instructions to stop rituals correspond to progress up the exposure hierar-
chy (use of gradual response prevention is further discussed later). Table
11.1 lists important considerations for planning response prevention.
Attend to Subtle Safety Behaviors. It is essential that the therapist

train the patient to understand that rituals and safety behaviors are not de-
fined by the complexity or repetitiveness of the action, but instead by their
effects on obsessional fear. Anything done to deal with obsessional
thoughts, reduce anxiety, or prevent feared consequences is a potential
safety behavior. Because popular descriptions of OCD typically highlight
classic compulsions such as prolonged washing or elaborate checking, pa-
tients (and therapists) sometimes overlook brief or subtle safety maneuvers
that are equally anxiety reducing and therefore play an equally important
TABLE 11.1
General Considerations for Planning Response Prevention
• Be aware that patients may not always realize that certain behaviors (e.g.,
subtle mental rituals) are violations of response prevention.
• Target efforts to seek assurances.
• Help the patient choose to refrain from rituals.
• Limit response prevention to the taking of acceptable risks.
• Arrange for relatives to stop assisting with rituals.
• Complete abstinence from all rituals, neutralizing, and reassurance seeking
is the goal.
• Some patients require that response prevention be applied gradually.
256 CHAPTER 11
role in the maintenance of OCD. Even subtle rituals and safety behaviors
must be targeted in response prevention. For example, one patient with
fears of losing things would tap his pocket as a subtle check that he had not
left his keys somewhere. Another wiped her hand on her pants to decon-
taminate. Further examples include visually inspecting people’s facial ex-
pressions, opening doors with a barrier (sleeve, tissue), and mentally
reviewing (or keeping a record of) one’s behavior through the day to make
certain that no awful mistakes were made. These more or less fleeting ef-
forts to reduce discomfort are often not reported to the therapist because
patients do not realize they constitute escape from obsessional fear. How-
ever, if they persist, treatment outcome can be attenuated. Patients must
therefore recognize and report even “little actions” performed to reduce ob-
sessional distress.
Target Efforts to Seek Assurance. Some patients have an especially

difficult time not being reassured of safety and, to reduce their anxiety, en-
gage in incessant subtle and not-so-subtle strategies to attain reassurance.
One individual who feared contamination from pesticides insisted that he
and the therapist meet with a pesticides expert to define a safe level of expo-
sure. When it was agreed that the instructions included with particular
products would be used to guide ERP tasks, he excessively reread safety in-
structions, continued to ask frequently for assurances from the therapist
(e.g., “Are you sure this is safe?” “Would you hold your child this close?”
“Would you eat without washing your hands after doing this?”), and even
made extraneous visits to gardening stores to speak with additional “ex-
perts.” Further, he engaged in subtle forms of reassurance seeking during
exposure, such as performing crude risk analyses and trying to recall the
percentage of bug spray (parts per 100) that contained the active ingredient.
These behaviors interfere with progress in ERP because they prevent direct
exposure to the feared situation, which involves being uncertain about the
consequences. Because overcoming OCD means learning to live with ev-
eryday uncertainties, attempts to gain reassurance should be identified and
eliminated as part of the response prevention plan. Of course, compulsive
reassurance seeking must be handled with caution because miscommuni-
cations can derail the collaborative therapeutic relationship. In chapter 14, I
describe some helpful ways to address these problems.
Present Abstinence as a Choice. Because response prevention is gen-

erally conducted between sessions by the patient, he or she must be encour-
aged to choose not to perform safety behaviors when the urge to do so
mounts. No one will be looking over the individual’s shoulder to make sure
that every safety behavior is resisted (indeed this is impossible for mental
safety behaviors). However, some patients believe their rituals are involun-
tary and cannot be controlled voluntarily. It is important to empathize with

such a position, but also to point out that there have probably been times
when a ritual was delayed or postponed. This suggests that with hard work
and perseverance, such behaviors can be regulated. Therapists are encour-
aged to repeatedly remind patients of the importance of refraining from
safety-seeking behavior, but also to caution them against excessive self-crit-
icism founded on unrealistic perfectionism, as at least some violations of re-
sponse prevention are inevitable.
Therapist: I realize that just stopping your rituals and other safety be-
haviors cold turkey is going to be difficult for you. You might
even feel like you can’t do it. Doing response prevention can
be very hard, but it is not impossible. Think of the times when
you delayed your rituals for a little while for one reason or
another—last time you mentioned that you sometimes resist
washing your hands until you are alone. So, although it may
not seem like it, performing rituals is very much a choice that
you make. And in order to reduce your OCD symptoms, you
have to choose not to ritualize and instead choose to let your-
self be anxious for a while. Although this is a difficult choice,
it is within your power and I will expect you to try. Remember
that once you get some practice and see that your anxiety is
temporary, you will also see that it becomes easier and easier
to resist rituals, and the compulsive urges will become
weaker and weaker.
Kozak and Foa (1997) pointed out that the very term response prevention
can imply that somebody actively stops the patient from performing ritu-
als. Of course, as a rule, this is not the case—and the therapist must make it
very clear that the decision to adhere to ERP instructions is ultimately the
patient’s. At most, the therapist might gently cajole, distract, or redirect
the patient to help him or her resist ritualistic urges, but no physical force
is ever used.
Define the Limits of Response Prevention. As with exposure, the re-

sponse prevention plan should involve taking only acceptable risks. If
broad instructions such as “no checking mirrors while driving” or “no con-
tact with water” are imposed, provisions or adjustments should be made
where actual health, hygiene, and safety concerns exist. For example, it is
important to check the rearview mirror when backing up in the car; thus pa-
tients fearful of injuring others can be limited to one brief check. Similarly,
denying a daily wash or toothbrushing violates cultural hygiene norms;
thus one daily 10-minute shower can be permitted as long as the shower
258 CHAPTER 11
does not involve the completion of rituals and the patient re-exposes him-
self or herself to feared contaminants immediately afterward.
Engage Relatives in Response Prevention. As I have discussed, pa-

tients’ friends or relatives sometimes become entangled in compulsive rit-
uals, avoidance, and other efforts to gain reassurance. One patient
required his family to carry out elaborate decontamination rituals before
entering the home. Another gained reassurance by merely mentioning to
her husband when she perceived potential danger (e.g., pins, glass on the
street). She believed that his acknowledgment of these warnings absolved
her of responsibility for any harm that might ensue. A good rule of thumb
is that the patient is to refrain from asking others for the following: (a) as-
surances, (b) to engage in any avoidance behavior, and (c) to perform any
rituals. If such appeals are made, others should be instructed not to pro-
vide assistance or assurance. It is wise to have at least one family member
attend the treatment planning sessions to be given the rationale and spe-
cific instructions for helping the patient with response prevention. The
specifics involved with preparing an appropriate support person for this
role (e.g., teaching them how best to respond to requests for assurance) are
discussed later in this chapter.
Abrupt Versus Gradual Response Prevention. The expectation that

patients cease all safety behaviors is sometimes difficult to reconcile with
the use of a graduated exposure hierarchy. That is, patients may have un-
planned encounters with feared stimuli that evoke very strong urges to rit-
ualize, but that have not yet been practiced in session. Thus, the patient
may not have practiced resisting his or her ritualistic behavior in response
to such stimuli. As an alternative to starting complete response prevention
from the first session, therapists might consider a gradual approach in
which instructions to stop safety behaviors parallel progress up the expo-
sure hierarchy (with the goal being complete abstinence midway through
treatment). Summerfeldt (2004) advocated a stepwise approach in which
the patient initially practices delaying the ritual, and where the delay inter-
val (i.e., between exposure and safety behavior use) is gradually increased
until compulsive urges subside and complete abstinence can be attained.
The following text illustrates the use of a gradual approach for a patient
with severe contamination concerns.
Andrea’s main fear was that she would contaminate others with her “nega-
tive essence” that was especially concentrated in her genital area. She worked
as a physician’s assistant and had ready access to Betadine, an abrasive
cleanser that she used with high frequency both at home and at work. While
at work, she managed to function by wearing three layers of gloves, which
went unchallenged by coworkers. As a medical professional, she acknowl-
edged that her concern was irrational, yet she was so fearful of the possibility
of harming others that she was engaging in extensive avoidance and safety
behaviors. For example, at her initial consultation, Andrea reported that she
had not touched the lower half of her body in 5 years without using a barrier
(e.g., glove) to prevent direct contact with her skin.
The most fear-evoking item on Andrea’s exposure hierarchy was touching
her genital area with her bare hand. However, when Andrea’s therapist de-
scribed the rationale for complete response prevention, Andrea said she
would discontinue treatment if it meant eliminating barriers when touching
herself. The therapist assured Andrea that many patients feel the way she did,
and that gradual exposure to her feared situations would make refraining
from her safety behaviors easier. However, Andrea asserted that once her use
of barriers was eliminated, she would be forced to confront her worst fear al-
most immediately, because she would have to wipe herself after urinating
and defecating without any protection. Even at home, she was using abrasive
cleaners, triple gloves, and engaging in an extensive laundry ritual that re-
duced her fears of becoming contaminated by her genitals and spreading the
contamination with her hands.
The therapist acknowledged that it would be overwhelming for Andrea to
give up all rituals and safety behaviors from the start of treatment, and thus
a gradual response prevention plan was created. Andrea would progres-
sively eliminate each set of gloves as she practiced exposure to certain stim-
uli, until she was wearing no gloves and doing no washing in her home or
work environment. For example, it was acceptable for her to use single
gloves after defecating and urinating until such time that these items were
confronted on the fear hierarchy. Only after she had refrained from rituals
for 2 consecutive days were exposures to directly contacting skin on the
lower half of her body implemented. This graded response prevention plan
allowed Andrea to avoid confronting her greatest fears until it was time to
conduct exposure to these stimuli.
Handout 11.1 provides space for recording patient-specific response

prevention instructions. After agreeing on the specifics of which behaviors
will be stopped and when, these details should be written down on the
form and given to the patient.
SPECIFIC RESPONSE PREVENTION GUIDELINES

FOR OCD SYMPTOM DIMENSIONS
Harming
Patients with harming symptoms must refrain from all checking rituals, as
well as other efforts to prevent feared consequences or to gain assurance
that negative outcomes will not occur (e.g., picking up objects from the
ground, counting, reporting potential hazards to others, retracing steps,
making lists). In addition, family members may not perform these behav-
iors by proxy. If checking involves simply looking at something (e.g., at a
lightswitch or lock), such objects can be covered or masked (e.g., with a
piece of paper) to obscure them from view. For patients afraid of mistakes,
paperwork may be checked once (briefly), but without the use of spelling or
Handout 11.1. Help with Response Prevention form.
260
grammar-checking software. Reviewing mathematical calculations is not

permitted. Mentally reviewing past behavior or conversations, and seeking
information or advice that has already been given (e.g., questioning for re-
assurance) also constitute rituals and must be halted. When ritualistic
prayers or other mental neutralizing strategies are difficult to stop com-
pletely, the patient can, as a preliminary step, be instructed to purposely
perform these safety behaviors incorrectly, or in a way that leads to feeling
uncertain about feared consequences. Examples include counting to the
wrong number, praying incompletely or for the wrong outcome, and re-
membering actions incorrectly. Family and friends should be instructed not
to respond to requests for assurance, but instead to engage the patient in an-
other activity as a temporary distraction (e.g., “I know you feel like you
need me to reassure you, but Dr. ____ said it is best if I don’t answer that
question. So, how else can I help you feel less anxious?”). For gradual re-
sponse prevention, seeking assurances may be permitted only if the corre-
sponding situation has not yet been addressed in exposure.
Contamination
Bodily contact with water should be limited to one daily 10-minute
shower (which should be timed). The shower should be ineffective as a
decontamination ritual and serve merely to maintain minimal standards
of hygiene (specific rules will vary from patient to patient). Hand washing
after activities such as using the bathroom and taking out the garbage,
and before handling food, is prohibited. Toothbrushing is allowed, yet
shaving should be done with an electric razor to minimize water use.
Other methods to remove or prevent contamination, such as hand wiping
and the use of sanitizing gels, are not permitted. Cleaning inanimate ob-
jects (e.g., doing extra laundry loads, wiping furniture) is also not allowed
and patients should not use barriers (e.g., tissues, gloves, shirt sleeves)
when touching surfaces. Finally, friends and family members are not to be
asked to follow any rules for avoidance or decontamination. Of course,
cleaning or washing is allowed in extenuating circumstances, such as if
grease is visible on one’s hands or clothes. However, after any washing or
cleaning, the patient should recontaminate with items from the fear hier-
archy to maintain exposure.
Incompleteness
Patients with incompleteness symptoms must refrain from rituals per-

formed in response to a sense of inexactness, unevenness, imbalance, and
general imperfection. Objects may not be reordered, cleaned, or rear-
ranged. Efforts to balance things out (e.g., counting to an even number,
touching the left side if only the right side was touched) must be resisted.
262 CHAPTER 11
For some patients, counting is performed mentally and feelings of symme-

try or order are achieved visually (e.g., by looking or staring in specified
ways) or with special bodily movements (e.g., tapping) or vocalizations
(e.g., repeating words or phrases). Because of their pervasiveness, abrupt-
ness, and subtlety, such rituals might seem automatic and difficult to stop.
A strategy that is often helpful in such cases is for the patient to initially
keep track of these rituals (e.g., using a handheld counter). Next, he or she
should practice performing the ritual incorrectly (e.g., counting to the
wrong number, staring the wrong way, saying the wrong words), so that it
does not relieve distress. This intermediate step eases the eventual com-
plete stoppage of the ritual.
Recall that some incompleteness rituals are performed to magically
prevent negative consequences such as bad luck or death. One man seen
in our clinic described the need to look at people’s facial features in a cer-
tain order to reduce intrusive distressing images of having his genitals
“lopped off.” In such cases, any behavior that reduces distress about en-
countering feared outcomes (including having unwanted images) must
be stopped. This example illustrates the overlap in symptom dimensions
that can sometimes occur between incompleteness and unacceptable
thoughts, as described next.
Unacceptable Thoughts
Response prevention for this symptom dimension targets all behavioral

and mental acts performed to neutralize or “put right” unwanted
thoughts. Of special concern are mental rituals. Specifically, patients must
resist urges to mentally cancel, replace, neutralize, analyze the meaning
of, or otherwise suppress their obsessions. Special prayers and confes-
sions for blasphemous obsessions are not permitted. Patients with sexual
thoughts and doubts must not review their sexual history or monitor their
body for signs of sexual arousal (a covert form of reassurance seeking).
Resisting and stopping such mental maneuvers is challenging if the pa-
tient is not properly socialized to the cognitive- behavioral model of OCD
and rationale for CBT, hence the importance of psychoeducation. One
common mistake is to confuse mental rituals with obsessions. The thera-
pist should frequently assess success with response prevention because
the persistence of mental rituals can reduce therapy effectiveness by im-
peding habituation to obsessions and preventing cognitive change. Be-
cause thinking obsessional thoughts is incompatible with neutralizing
them with mental rituals, the best form of response prevention for mental
rituals is continual exposure to the obsessional thought. Loop tape expo-
sure (as described in chapter 10) can therefore be used as both exposure
and response prevention. As a backup plan, mental rituals that cannot be
resisted may be performed incorrectly as described earlier.
When Patients Use Religious Rituals. Very religious patients who

suffer from unacceptable thoughts often need help differentiating between
healthy religious behavior on the one hand, and religious strategies that
they use expressly in response to obsessional thoughts on the other.
Whereas the former need not be targeted in response prevention, if the lat-
ter persist, they reinforce dysfunctional beliefs such as “Praying keeps me
from acting on unwanted sexual impulses.” In addressing this dilemma,
the therapist should show respect and understanding for the patient’s reli-
gious beliefs, yet help the patient see that some of his or her “religious” be-
havior is actually safety seeking and counterproductive. Whereas directly
confronting the patient with this fact might appear as an assault on his or
her religion, a suggested solution is to engage in a Socratic dialogue that in-
duces the patient into elaborating this point, as in the following example:
Therapist: It sounds like you often turn to prayers for managing your
obsessions; like to get rid of your unwanted sexual thoughts.
Patient: Yes. God is the only one who can save me from all my im-
moral thoughts and make them go away.
Therapist: And what effects do the prayers have on the obsessions?
Does praying make the thoughts go away?
Patient: Well, if they worked, I wouldn’t be here.
Therapist: What do you mean? Tell me more about that.
Patient: Even though I’m always praying to stop the thoughts, I’m
still having them as much as ever. I think that lately they’ve
even become worse, if anything.
Therapist: Interesting. So what you’re saying is that despite all your prayers,
the obsessions have intensified. What do you think that says
about praying as a strategy for managing obsessional thoughts?
Patient: Hmm [thinks to himself]. I never looked at it that way before.
Therapist: I know that prayer is important for you, and that it makes you
feel closer to God. But since you are telling me that praying
about the obsessions hasn’t worked very well, would you
consider learning a different strategy when it comes to deal-
ing with these thoughts?
Patient: Well, my pastor did say that I pray too much about the wrong
things. Maybe he was right.
Allowing the patient to take the lead in sorting out which religious be-
haviors could be labeled as part of OCD and which as part of routine reli-
gious practice may be helpful. Religious behavior motivated by
obsessional thoughts is not technically religious. Such behavior is fear
based rather than faith based. Therefore, effective treatment will help
the patient practice his or her religion in a healthier way (without obses-
sive fear). The assistance of family members and religious authorities
264 CHAPTER 11
who can reinforce the distinction between healthy and unhealthy reli-
gious practice may be necessary for implementing response prevention
for such patients.
INCLUDING FAMILY MEMBERS

AND FRIENDS IN TREATMENT
For many patients, assessment will reveal that family and friends have be-
come involved with OCD symptoms. Patients with checking rituals often
ask cohabitants to conduct a final examination of the doors and windows
before coming to bed. Those with contamination fears might require family
members to avoid certain areas of the house or engage in washing or clean-
ing rituals. Other patients repeatedly query relatives and friends for reas-
surance. Because treatment cannot be successful if such behavior is
occurring, it is important that family and close friends curb their participa-
tion in these symptoms. In addition, a particular support person can be
identified who will help the patient complete homework tasks and refrain
from rituals between sessions. In the following sections, I describe how to
prepare significant others for involvement in treatment.
Ending Family Involvement in Symptoms

Friends and relatives of the patient must agree to no longer respond in
ways that sustain OCD symptoms, and it is a good idea to stipulate with
family members or close friends some specific guidelines for ending
such behavior. First, family members must stop assisting the patient
with avoidance behavior. For example, parents are no longer to restrict
what they touch or who or what they bring into the house; and friends
should no longer avoid feared numbers or words (e.g., cancer). A second
guideline is that relatives must agree to refrain from helping the patient
perform compulsive rituals. For example, extra soap or wipes should no
longer be stocked in the house and spouses should refuse to check doors
and appliances or call poison control. Finally, those close to the patient
must stop responding to requests for reassurance. When asked ques-
tions such as “Do you think this will poison me?” “Did I pick up all of the
pieces of broken glass?” or “Should I confess about my bad thoughts?”
relatives should remind the patient that they have agreed not to answer
such questions any longer.
Certain challenges may arise when asking family members to end their
participation in OCD symptoms. For example, relatives may be concerned
that if they stop helping, the patient will be subjected to harmful levels of
anxiety. This underscores the importance of reviewing how anxiety is not
dangerous and how it subsides naturally even if rituals are not performed.
Another reservation concerns the prospect of hostility if the patient’s re-
quests for help are not met. Some patients manipulate others using tan-
trums and threats such as “If you don’t flush the toilet for me, I will go
berserk!” In such instances the therapist should acknowledge that it is diffi-
cult to change such behaviors, but that if treatment is to be successful, fam-
ily members must not help with OCD symptoms, and the patient must
agree not to act in hostile or otherwise manipulative ways. Reaching an
agreement before treatment begins regarding how such conduct will be
handled is often a good way to sidestep such problems.
The Designated Support Person

Choosing a Support Person. Help from a relative or close friend who
understands the symptoms of OCD and the demands of treatment is
likely to make the distress experienced during ERP easier for the patient
to endure. In chapter 7, I discussed certain characteristics to look for in a
potential support person. Briefly, the patient should choose someone who
is considerate, sensitive, and optimistic that treatment will be helpful. The
support person should also be warm, thoughtful, and willing to challenge
or confront the patient constructively and in a nonjudgmental way when
difficulties arise. Family members who appear overbearing, pessimistic,
sarcastic, highly critical, or antagonistic should not be selected because
greater harm might be done than progress made. On the other hand,
someone who is smothering or eager to become overly involved in treat-
ment is equally undesirable because he or she might inadvertently act in
ways that absolve the patient of his or her responsibility for getting well.
For this reason, it is recommended that the therapist meet and briefly eval-
uate the patient’s rapport with the support person before agreeing to their
coming on board.
Preparing the Support Person. It is helpful for the designated sup-

port person to be present intermittently during the treatment planning
phase so that he or she may be socialized to the cognitive-behavioral
model of OCD and the treatment rationale. For two reasons, I find it useful
to ask the patient to take the lead in teaching the support person(s) about
this material. First, this provides a guarantee that the patient has consoli-
dated this material well enough to explain it coherently to someone else
(the therapist can fill in gaps as needed). Second, it reinforces the patient’s
role as taking responsibility for his or her own treatment. It is helpful to
also have the support person present during the initial exposure sessions
so that he or she gets a sense of how treatment is implemented and what is
expected of the patient.
The support person’s role should be precisely clarified: It is to function
as an advisor to the patient. He or she should provide encouragement and
make suggestions and recommendations, typically when the patient re-
quests help or needs guidance. No threats or physical force are to be used
to change the patient’s behavior. The support person should not be “on
266 CHAPTER 11
the patient’s back.” Examples of useful comments that support persons

can make at various junctures during treatment are presented in Table
11.2. These might be reviewed, and role plays conducted, to ensure that
such comments are given appropriately. Patients should be instructed to
call on the support person when they feel they need help. My colleague
Dr. David Tolin has developed a useful handout for reviewing these ar-
rangements and agreeing on a specific plan (see Handout 11.2). The hand-
out, which is to be reviewed during treatment planning, includes a
contract defining the roles of the patient and support person. It also rein-
forces a team approach to overcoming OCD.
Susan elected to have her husband, Steve, serve as her support person. Steve
and Susan appeared to have a sound marriage and seemed to communicate
well with each other. After discussing how Susan and Steve interacted re-
garding Susan’s problems with OCD, the therapist agreed that Steve would
be a fine source of support for Susan. Although Steve was also interested in
helping his wife, he understood that his role was not to scrutinize her behav-
ior, but instead to be there for her when she needed him. When not physically
in the same place, he agreed to be available by cellular phone as much as pos-
sible. Handout 11.2 was then reviewed and Steve was invited to attend the
first exposure session.
CLARIFYING THE TREATMENT PLAN
When completed, the fear hierarchy and response prevention plans repre-
sent a contract that must be explicitly endorsed by both the patient and
therapist. Mutual agreement on how exposure sessions will proceed helps
build the patient’s trust that there will be no surprises. It also gives the ther-
apist leverage if the patient refuses to engage in certain exposures. Never-
theless, flexibility is important because unanticipated factors that are
beyond the patient’s or therapist’s control inevitably influence the course of
treatment. For example, the initial fear hierarchy is subject to alteration if it
becomes clear that the patient is having difficulty managing associated dis-
tress. In such cases the planned exposure may be temporarily tabled in fa-
vor of intermediate situations that evoke less distress.
Before beginning ERP, Susan’s therapist reiterated key points about the
treatment plan and what would be expected of Susan during treatment.
Steve was present for this discussion.
Therapist: Over our last few meetings we have exchanged a great deal of
information. You have taught me about the particulars of
your OCD symptoms and I have taught you how to think
about these symptoms in a way that will help us to reduce
them. We have also put together a plan for reducing your
TABLE 11.2
Comments for Support Persons to Use
When Assisting Patients with OCD Treatment
During homework exposure practices

• I know this must be hard for you, but you’re doing a good job so far.
• Remember that the anxiety is temporary. Think of how good you’ll feel when
you’re finished.
• Remember what Dr. _________ said … you have to make yourself anxious to
get better.
• Let’s talk about the realistic chances that harm will actually occur.
• If you stop now, you’ll only be making OCD worse. It’s worth deciding to be
anxious.
• We can take a break as long as we decide now when we are going to try again.
• I’m sorry that you have decided not to do the exposure. We’ll have to let Dr.
________ know.
If the patient is having difficulty resisting urges to ritualize or seek reassurance
• Let’s go for a little walk and maybe that will help.
• Remember that your urge will go down, but only if you keep resisting.
Remember, the anxiety is temporary.
• It sounds like you want reassurance, but we all agreed that it is not helpful
for me to answer that question.
• Do you really think ________ will happen if you don’t ritualize? Let’s talk
about that.
• I know it’s hard to resist doing rituals. What can I do to help you get through
this tough time?
• I don’t think you’re making a good choice here, but I realize it’s hard for you.
Make sure you write down that you did a ritual so that we can talk about it
with Dr. _______. There will be other chances for you to practice more.
If the patient is avoiding fear-evoking situations that have already been addressed in
exposure sessions
• By avoiding you are just making OCD stronger. I think you’re making a bad
choice.
• I know it’s a challenge, but you can do it. Confronting will help you over-
come OCD.
• What evidence is there that this is dangerous? Let’s look at the realistic
probability of harm.
• Remember what happened when you confronted this situation before? You
eventually felt much less anxious. There is every reason to think the same
thing will happen if you face your fear again.
267
Handout 11.2. “Please Help Me With My OCD.” Developed by David F. Tolin, PhD, The
Institute of Living, Hartford, CT. Adapted with the permission of David F. Tolin, PhD.
268
symptoms in which you will practice confronting the situa-

tions and thoughts that evoke obsessional fear while refrain-
ing from maladaptive behaviors such as washing and
checking rituals. Before we start, I want us to review this
treatment plan one last time to be sure we are on the same
page about how therapy will progress from here.
The therapist then showed Susan a copy of the fear hierarchy (see Fig. 10.2).
Therapist: As we have talked about, when you avoid situations that

evoke obsessional fear, like public bathrooms, you are able to
hide from your OCD symptoms. However, avoidance is not a
good long-term solution because it prevents you from being
able to tell whether your obsessional fears are unfounded. So,
avoidance prevents you from getting over OCD. Beginning
with the next session, I will help you to practice confronting
the items listed on the fear hierarchy that we developed to-
gether. You will start with exposure to situations that evoke
moderate levels of anxiety and work up to facing more diffi-
cult situations that you perceive as highly risky or dangerous.
Of course, the exposure tasks will more than likely produce
feelings of anxiety, especially in the beginning. After all, you
have been trying to avoid these situations as much as you
can. However, it is important for you to remember that your
anxiety will diminish during the exposure session by the pro-
cess of habituation. Each time you practice an exposure, your
symptoms will decline further and further. Exposure exer-
cises will also help you to correct mistaken beliefs about risk
and danger associated with your obsessional thoughts and
situations. For example, by repeatedly touching the toilet,
you will find out that toilets do not usually make people sick.
As a result of habituation and the correction of mistaken
beliefs, exposure situations will become easier and easier to
face. This is how your obsessional fear will be weakened. I
will also be giving you exposure tasks to complete between
sessions and I expect that you will devote ample time and ef-
fort to these practices. To get better you will need to consis-
tently practice confronting, rather than avoiding, situations
that evoke obsessional fear. If you have trouble with doing
these exposures, you should ask Steve to help you.
Next, the therapist addressed response prevention and the seemingly

strict guidelines for curtailing all rituals. It is important that the patient un-
270 CHAPTER 11
derstand the reason for putting these rules into place. Susan’s response pre-
vention plan is shown in Fig. 11.1.
Therapist: Exposure will probably also make you want to do rituals and
other safety behaviors to relieve your anxiety; after all, that
has been your pattern of responding to obsessions for a long
time. However, while rituals might make you feel better in
the short term, they are not a good long-term solution be-
cause they prevent you from getting over OCD. For example,
how can you ever learn that trash cans aren’t dangerous if
you always wash your hands immediately after throwing
FIG. 11.1. Susan T.’s response prevention plan.

something away? So, starting at our next session, you must

also agree to work very hard on stopping all of your compul-
sive rituals and other strategies to neutralize obsessional fear.
In addition, you are not to ask other people to ritualize for
you or to do anything else to help you cope with obsessional
fear by avoidance. This is the response prevention compo-
nent of CBT. Only when all rituals are stopped can you learn
that these behaviors are not necessary to keep you safe. If you
continue to do rituals like washing and checking, it will un-
dermine exposure. There is no point in exposing you to
touching toilets if you are going to take a long shower after-
ward since you would never learn that toilets are not as
threatening as you fear.
You can expect that at times, resisting the urge to wash,
check, and dismiss intrusive thoughts will be difficult for
you. If you feel you cannot resist doing a ritual, you should
find Steve and ask for his help; he has agreed to assist by dis-
tracting you or by helping you think more clearly about your
fears. If you are still unable to resist doing a ritual, or even if
you do one without thinking about it, you need to let me
know by recording what happened on your self-monitoring
forms. I will not be upset with you if you ritualize, but instead
we will use the opportunity to problem solve about ways to
help you better resist these compulsions. Also, any rituals
should be followed by immediate re-exposure to the situa-
tion or thought that triggered the rituals.
This handout (referring to Fig. 11.1) contains your goals
for response prevention. I know that some of the rules we
have set up go beyond what people ordinarily do. I know that
while most people are encouraged to wash their hands after
using the bathroom or before they eat, you are not supposed
to do these things during treatment. The reason for restricting
your washing and cleaning is to help you change your beliefs
about danger. That is, by not washing, you will give yourself
the opportunity to find out that all of the extensive washing
you were doing was unnecessary and that even if you resist
urges to wash, you are unlikely to get sick or make others
sick. Do you have any questions about this plan?
Next, the therapist reiterated his own role in the therapy program. Ac-
tive treatments such as CBT are collaborative efforts between the therapist
and patient. This means that the patient, therapist, and any support per-
sons agree to form an alliance against OCD. The therapist is viewed as an
272 CHAPTER 11
expert, teacher, or coach, and the patient as apprentice or pupil. The thera-
pist’s job is to listen to the patient’s concerns, teach skills, and encourage.
The patient’s job is to express his or her difficulties, practice, learn, and
implement what he or she is learning.
Therapist: As I have said before, you can think of me as your coach and
your cheerleader. As your coach, my job is to help you learn
and practice techniques that will reduce your OCD symp-
toms. These techniques help many people with OCD, but
only when they are used in the right way. So, your job will be
to practice these techniques in the exact way that I coach you
so that you can get the most out of them. If you don’t practice
them correctly, you will reduce the chances of getting over
OCD. This means that the responsibility falls on you to let me
know when you are having trouble, need my help, or if you
are upset with me or do not want to follow my instructions. It
is important that we openly discuss and try to resolve any
concerns that you have. If you do not bring these problems to
my attention, you might end up missing out on opportunities
to take advantage of my coaching. As a coach, it is not my job
to force you to practice the techniques I teach you, and so I will
not try to do this.
In my role as cheerleader, I will be supporting you every
step of the way as you implement your new skills. I will help
you troubleshoot and encourage you to work your hardest. I
will also give you a pat on the back when you do a nice job
and try to motivate you to stick with it if the going gets tough.
So, do you agree to this treatment plan?
The treatment planning phase concludes with a discussion of any ques-

tions or concerns raised by the patient or any others who have joined the
session. When the patient indicates acceptance of the treatment plan, the
initial exposure session can begin.
12
Conducting Exposure
Therapy Sessions
Exposure and response prevention are the essential component of CBT for
anxiety disorders. In the case of OCD, successful long-term improvement
requires that the patient repeatedly confront obsessional stimuli directly
and without engaging in safety behaviors such as compulsive rituals, neu-
tralization, or reassurance seeking. Therapeutic exposure elicits obses-
sional fear, which is then allowed to decline while the patient remains
exposed to the obsessional stimuli. Cognitive techniques are also used to fa-
cilitate the correction of catastrophic beliefs that underlie OCD symptoms.
This chapter discusses how to conduct exposure therapy sessions for OCD.
It covers procedures for acclimating patients to the treatment procedures,
assisting them with gradually confronting stimuli of greater and greater
difficulty, and assigning and reviewing homework exposure practice. The
integration of cognitive techniques with exposure is highlighted through-
out the chapter. As in previous chapters, Susan T.’s case is used to illustrate
how exposure procedures are commonly implemented.
273
274 CHAPTER 12
GETTING THE MOST OUT OF EXPOSURE:

CAPITALIZING ON COGNITIVE AND BEHAVIORAL
MECHANISMS OF CHANGE
The initial explanations for how exposure procedures reduce anxiety were
couched in behavioral terms: With repeated and prolonged exposure, clas-
sically conditioned fear responses gradually diminish by the process of ha-
bituation or desensitization (Stampfl & Levis, 1967; Wolpe, 1958). Later
theories proposed a cognitive mechanism: Confrontation with fear-evok-
ing stimuli, in the absence of the expected feared consequences, provides
the patient with corrective information that disconfirms catastrophic be-
liefs that cause obsessional anxiety (Foa & Kozak, 1986). Although CT is
also proposed to reduce anxiety by correcting irrational beliefs, exposure
procedures are actually more persuasive vehicles of cognitive change than
are verbal CT techniques. In acknowledgment of this, some authors include
exposure techniques (renamed behavioral experiments) as core compo-
nents of CT (e.g., Van Oppen & Arntz, 1994). Used in this way, the condi-
tioning or habituation explanation is dropped and exposure is used
expressly to test predictions about the dangerousness of situations and the
need for safety behaviors.
However, using exposure therapy with the intention of modifying
faulty cognitions does not rob this technique of its behavioral effects (i.e.,
habituation). In fact, habituation itself provides a major source of cogni-
tive change: Patients learn that their anxiety remains manageable and
subsides over time even if safety behaviors are not performed. In addition
to providing ideal conditions for modifying cognitions, exposure therapy
affects the patient’s self-concept. By facing feared situations and develop-
ing healthy coping strategies, the individual is forced to modify negative
representations of the self, leading to a sense of confidence that he or she
can manage the situation (Tallis, 1995). Such changes probably contribute
to the patient’s decision to persist with intrinsically difficult treatments
such as ERP. Therefore it is most beneficial for therapists to capitalize on
the fact that ERP can produce change through both cognitive and behav-
ioral mechanisms. Accordingly, the exposure procedures described in this
chapter include systematic repeated and prolonged confrontation with
feared stimuli in the absence of safety behaviors (to promote the habitua-
tion of fear). These exercises are framed in terms of their effects on
cognitions (to promote the correction of faulty beliefs).
Unfortunately, the dialogue that takes place between patient and thera-
pist during the implementation of exposure often receives short shrift in
descriptions of ERP. Nevertheless, the use of CT techniques (as described in
CONDUCTING EXPOSURE THERAPY SESSIONS 275
chapter 9) to assist patients with examining and modifying their thinking in

the context of exposure likely contributes to exposure’s effectiveness. As I
illustrate in this chapter, cognitive interventions can be utilized at various
points during exposure sessions to promote adherence and facilitate symp-
tom reduction. When preparing for each exposure exercise, cognitive tech-
niques are used to help identify the key mistaken cognitions and feared
consequences. The importance of learning to take risks and manage accept-
able levels of uncertainty should also be discussed. During exposure exer-
cises, cognitive interventions can be used to develop healthy psychological
responses to obsessional fear (e.g., “I must confront my fear to prove to my-
self that harm is unlikely,” or “Even if I initially feel anxious, these feelings
subside if I do not do any rituals”). After completing an exposure task, cog-
nitive techniques are used to help the patient review the outcome of the ex-
ercise, examine evidence for and against catastrophic beliefs, and develop
more realistic beliefs about obsessional stimuli.
THE STRUCTURE OF EXPOSURE SESSIONS
Optimally, 90 minutes should be allotted for each exposure session. This

is usually sufficient time to allow patients to experience habituation of
anxiety. Each appointment should begin with a 5- to 10-minute check-in
and review of the past session’s homework assignment, which includes
examination of self-monitoring forms and exposure practice forms (dis-
cussed later in this chapter). Next, the prearranged exposure task is in-
troduced and the patient confronts the feared stimuli in vivo or in
imagination. The actual duration of exposure is determined by the pa-
tient’s anxiety level. As described later, exposure is terminated when the
patient’s anxiety level (i.e., SUDS) has decreased to at least 50% to 60% of
its initial (or peak) level. Ideally, the patient should remain in the feared
situation until he or she experiences only a mild sense of subjective dis-
tress. About 15 minutes at the end of each session should be allocated for
debriefing, assigning homework practice, and discussing the next ses-
sion’s exposure task.
EARLY EXPOSURE SESSIONS
On an organizational note, because Susan T.’s first exposure targeted con-

tamination fears (see Fig. 10.2), this section simultaneously illustrates how
to conduct early exposure sessions, as well as how to implement exposure
for contamination symptoms. Later sections of this chapter illustrate the
276 CHAPTER 12
implementation of exposure for the harming, incompleteness, and unac-

ceptable thoughts symptom dimensions.
Preparing the Patient
Early exposure sessions should begin with a brief review of the cogni-
tive-behavioral model of OCD and rationale for ERP. The therapist might
“quiz” the patient on this information by asking questions such as, “Why
will purposely facing the situations you are afraid of help you reduce
OCD symptoms?” Some patients are skeptical about exposure therapy on
the basis of previous attempts at confronting obsessional stimuli that
failed to reduce fear. If this point is raised, the therapist should draw a dis-
tinction between typical exposure and therapeutic exposure. Whether de-
liberately or by accident, most patients at some point encounter their
feared stimuli. However, in most cases, they manage to avoid direct or
prolonged exposure and are inclined to ritualize as soon as possible after
the encounter. This is referred to as typical exposure because it is character-
istic of how the patient has used maladaptive OCD habits to handle con-
frontation with obsessional stimuli. In contrast, therapeutic exposure is well
planned, involves rational thinking, is performed without avoidance or
safety behaviors, and lasts until anxiety subsides on its own. If the patient
experiences a sense of relief on terminating exposure, it will reinforce
avoidance habits as well as the belief that feared consequences are likely.
Only systematic, prolonged, and well-controlled exposure practices are
sufficient to reduce obsessional fears at the gut level. Such practices must
be repeated until they no longer evoke distress. Handout 12.1, “Guide-
lines for Effective Exposure Practice,” helps to clarify expectations for
how exposure sessions should proceed. The handout should be reviewed
with patients before getting started.
Managing “Cold Feet”
Therapists should be prepared to offer comfort and encouragement if the pa-

tient reports apprehension before beginning the first exposure. Susan’s ini-
tial exposure involved touching communal surfaces such as door handles,
stairway railings, elevator buttons, and public telephones. However, she ex-
pressed trepidation at the prospect of beginning this task. The therapist un-
derstood her concerns and explained how the session would proceed.
Therapist: You look apprehensive. What are your thoughts about doing
this exposure?
Susan: I’m a little scared. I don’t know what to expect and I don’t like
feeling anxious.
Handout 12.1. Guidelines for effective exposure practice.
277
278 CHAPTER 12
Therapist: I understand. Would it help if I told you how I think we

should proceed?
Susan: Sure.
Therapist: First, you will be in the driver’s seat. My job is only to help
you get the most benefit from the exercise. So, we will go
around touching door handles, railings, and elevator but-
tons that you are afraid will produce illness. I will be moni-
toring your level of distress, but you should also feel free to
let me know how you are doing. I will also be helping you re-
sist any urges to ritualize. At first, I expect that you will feel
uncomfortable. But you will see that your distress subsides
over time. We will stop the exposure when your anxiety has
decreased considerably from the starting level. Then, we
will discuss what you learned from doing the exercise, and
come up with some situations for you to practice on your
own before the next session. How does that sound?
Susan: Scary, but I know it’s what I have to do. Let’s get started.
Introducing the Exercise
The therapist begins by describing how the feared stimulus will be confronted,
for how long, and what kinds of behaviors are not permitted. A brief descrip-
tion of the exercise can be entered on the Exposure Practice Form (Fig. 12.1),
which is used to keep a record of beliefs and SUDS levels during the exposure
session. Susan’s therapist introduced Susan’s first exposure as follows:
Therapist: We’ll begin the exposure gradually so that you ease yourself
into it, but my goal is for you to “contaminate” yourself with
“germs” from surfaces other people often touch. So, first
we’ll walk around the clinic, then we can go to some nearby
places; and your job will be to practice touching things. I will
be asking you to rate your SUDS level every 5 minutes, so
have a number between 1 and 100 in mind.
Eliciting Dysfunctional Beliefs
The therapist should be able to anticipate the patient’s dysfunctional beliefs

about the feared consequences of exposure to the selected hierarchy item(s).
Typical examples include an exaggerated fear of harm as well as the fear that
anxiety will persist if safety behaviors are not performed. If such negative pre-
dictions cannot readily be identified, the therapist should specifically inquire
about fear of anxiety or discomfort (“Do you worry that you would never be
FIG. 12.1. Exposure Practice Form for use with in-session exposure tasks.
able to feel comfortable if you were exposed to this situation without doing rit-
uals?”). The feared consequence should be clarified as specifically as possible
because it is this belief that the exposure task needs to disconfirm. Once identi-
fied, the belief is recorded on the Exposure Practice Form. Susan’s therapist ex-
plained the cognitive aspects of exposure as follows:
Therapist: During exposure, we will be putting your fears to the test. So,
before we start, what are you afraid might happen if you
touch things like door handles and public telephones, know-
ing that washing your hands is off limits?
280 CHAPTER 12
Susan: I could get sick or spread germs and make other people sick.
You never know who put their hands there last.
Therapist: [writes these beliefs on the Exposure Practice Form] So, how
likely is it (what percent) that you will get sick if you touch
door handles without washing?
Susan: Not too likely … maybe about 30%. [Therapist writes the
probability estimate on the form.]
Therapist: And how severe would it be if your fears came true?
Susan: About 75%. [Therapist records severity rating on the form.]
Introducing the Feared Stimulus

After obtaining a baseline SUDS rating (Susan’s was 50) the feared item is
presented. It is a good idea to begin contamination exposures gradually
and observe how the patient responds. If he or she eagerly “jumps in,” rein-
force this and follow the lead. If things are progressing very slowly, some
encouragement might be needed to pick up the pace. If necessary, the thera-
pist can model initial contact with the feared stimulus. Patients are encour-
aged to focus on, rather than distract themselves from, the exposure
stimulus (Grayson, Foa, & Steketee, 1982, 1986). Regularly asking ques-
tions such as “How are you feeling now?” “What are you telling yourself?”
or “What’s your SUDS?” is a good way to maintain this focus and to contin-
ually assess thoughts and feelings during the exercise.
Susan and her therapist walked to the door of another office in the clinic.
The therapist first modeled exposure by grabbing hold of the door handle
and instructing Susan that she would be expected to do the same when it
was her turn. It is important for patients to fully confront feared contami-
nants. Briefly touching items with fingertips does not make for adequate
exposure. Patients must feel thoroughly contaminated.
Therapist: Now, I’d like you to do what I’m doing.

Susan: [hesitates] … OK. [holds on to the door handle] There, I’m do-
ing it.
Therapist: Great … Make sure you have good firm contact … So, how
does it feel?
Susan: My head is spinning a little. I’m nervous. I don’t know who
else has touched this or where they had their hands.
Therapist: Well, that’s true. I don’t know who has touched this either.
But most likely, it’s safe enough. After all, people use door
handles all the time. What’s your SUDS now?
Susan: About 60.
Therapist: How strong is your urge to wash right now?
Susan: Pretty strong. I would definitely like to wash my hands.
Therapist: You’re doing a great job. Keep holding on.
Note how the therapist amplified Susan’s sense of uncertainty regard-

ing who else had touched the door handle, yet also modeled a noncata-
strophic response to this uncertainty. This maneuver helps the patient
learn alternative ways to view acceptable levels of risk and uncertainty
(i.e., as nonthreatening). Note also the use of praise for following through
with exposure tasks. This is an important rhetorical strategy for encourag-
ing adherence.
The therapist then gave Susan two paper towels and asked her to con-
taminate them with “door handle germs” by touching the paper towels to
the door handle. Next, the exercise was repeated with several other door
handles, a hand railing, a public telephone, and elevator call buttons. At
each step, the paper towels were used to collect “germs.” Every 5 minutes
the therapist inquired about Susan’s SUDS ratings. After about 10 minutes
of touching these surfaces, Susan’s SUDS had decreased to 50. At that point
they returned to the office to continue the exposure using the contaminated
paper towels. Sitting in a chair, Susan spread the paper towels out in her lap
and placed her hand on top of them. She acknowledged feeling quite con-
taminated. Over the next 10 minutes, though, her SUDS decreased to 40.
Amplifying the Exposure
Amplifying refers to purposely increasing the difficulty of an exposure to

address a particular aspect of avoidance or a specific dysfunctional belief.
For contamination exposures, amplification usually involves contaminat-
ing the parts of one’s body or inanimate objects that the patient would oth-
erwise try to avoid tainting. Common examples include the face, hair,
purses, wallets, lipsticks, and so on. Once Susan appeared less distressed
with the paper towels in her lap, the therapist encouraged her to spread the
contamination to other parts of her body:
Therapist: What’s your SUDS now?

Susan: I’m at about 40. I’m doing OK.
Therapist: Good. You look more at ease than you did a little while ago.
I’d like you to touch the paper towels to the rest of your body
… your arms, face, and hair.
Susan: Oh, I don’t know if I can do that.
Therapist: Would you like me to show you what I mean?
Susan: Sure.
Therapist: [Confidently takes one of the paper towels and rubs it on his
arms, legs, face, and hair]. There, now I’m all contaminated.
282 CHAPTER 12
Now, you try it. Spread the contamination all over and let
yourself feel totally tainted.
Susan: That looks really hard.
Therapist: Just take a deep breath and go for it. It will only get easier
from here.
Susan: [Takes the paper towel and thoroughly touches it to various
body parts including her face and hair.] There, I did it. Look at
that. I did it.
Therapist: Yes you did. Great going! That’s pretty brave. What’s your
SUDS?
Susan: 55.
About 5 minutes later, the therapist asked Susan to repeat this amplifica-
tion exercise. By this time, her SUDS had decreased back to 40. Exposures
should be reamplified every 5 to 10 minutes during the session until little or
no distress is evoked. Further discussion revealed that Susan was worried
contamination would spread to her purse, its contents, and various other
personal items such as her wallet, lipstick, and water bottle. She also feared
this could increase the chances of becoming sick. Therefore, subsequent
amplification involved tainting these items. After about 30 minutes of
exposure, Susan’s SUDS level was 30.
The therapist then reminded Susan that she would have to go the rest of
the day without washing or cleaning and asked if she could think of any
obstacles to adhering with the response prevention plan. Susan remarked
that eating would be particularly troublesome because she was concerned
that germs from her hands would be transferred to food. To address this
concern, the therapist suggested that Susan eat a snack (peanuts) off the
contaminated paper towels using her hands (contamination exposures
can often be amplified by having the patient handle and eat food during
the session). At first, Susan was reluctant. Yet after a discussion about her
mistaken beliefs concerning danger, and the fact that her anxiety had sub-
sided, she agreed to give it a try. After the therapist modeled eating sev-
eral peanuts that had been placed on the paper towels, Susan followed
suit. Although her SUDS initially increased with this exercise, after about
10 minutes, it had decreased back to 30. She said she felt more comfortable
about eating without washing. After 45 minutes of exposure, Susan’s
SUDS was 20 and the exercise was stopped. Susan was instructed to place
one of the tainted paper towels in her pants pocket and the other in her
purse to ensure that she remained contaminated for the rest of the day. She
was instructed to refrain from ritualizing, but that if she did violate re-
sponse prevention, she must record the violation on the self-monitoring
forms and recontaminate herself by either touching more public surfaces

or using the paper towels.
Careful Observation and Ongoing Assessment

The therapist should continually be on the lookout for subtle safety behav-
iors such as wiping one’s hands on one’s pants, opening doors with one’s
feet, or any other curious maneuvers that most individuals under similar
circumstances probably would not do. Patients who appear to “space out”
during exposure should be asked whether they are engaging in mental
strategies such as praying, reassurance seeking, distracting, or analyzing.
These safety behaviors limit the effectiveness of therapy because they pro-
tect the patient from direct exposure to feared stimuli and thereby prevent
the natural habituation of anxiety. These behaviors might also have become
so habitual that they occur without the patient’s awareness. Accordingly,
they should be brought to the patient’s attention whenever they are ob-
served, and strongly discouraged.
The therapist should be on the lookout for additional situations that
need to be incorporated into the present exposure or targeted in home-
work practices. Patients often make impromptu remarks about aspects of
the feared stimulus that they find especially fearful or distressing. These
comments reflect catastrophic cognitions. Susan, for example, mentioned
during the session that she would feel especially fearful if she contami-
nated her children’s belongings with germs from public surfaces. In other
words, she believed that she was likely to make her children sick. The
therapist must be attentive to such comments (and encourage the patient
to be open in reporting them) so that exposures can be designed to target
as specifically as possible the patient’s obsessional fears. Accordingly, Su-
san was encouraged to contaminate her children’s bedrooms with the pa-
per towels from the session (see the discussion of homework exposure
later in this chapter).
Incorporating Imaginal Exposure to Feared Consequences

Secondary imaginal exposure to feared consequences (see chapter 10) is of-
ten useful with contamination exposures. If not knowing whether feared
consequences will happen (or have already happened; e.g., “I could have
poisoned someone without realizing it”) is a source of anxiety, the scene
should focus on uncertainty (i.e., not knowing the outcome). Because Susan
described images of germs and fears of contaminating her children, an
imaginal exposure was conducted to these obsessional stimuli. The thera-
pist introduced the procedure as follows:
284 CHAPTER 12
Therapist: You told me about certain thoughts you were having, such as
images of germs and doubts about making your family sick.
When these obsessional thoughts occur, you are in the habit
of responding as if they are true just because you think them.
This leads to anxiety and makes you do rituals like washing
and cleaning just in case the thoughts are true. To help you
change the way you manage these obsessional thoughts,
we’re going to have you practice thinking about obsessional
thoughts without responding as you usually do. By practic-
ing this technique, you will see that your distress subsides
just like with situational exposure.
We will do this using a loop tape on which we will record
your obsessional thoughts. You will then listen to the tape un-
til it no longer evokes significant anxiety or urges to wash or
clean. Every now and then I will ask for your SUDS rating.
Susan was instructed to write a lengthy description of her images of

germs and of a scene in which she finds out that her children have become
sick because she inadvertently contaminated them. The scene was then ed-
ited with the therapist’s help and recorded onto a 2-minute loop tape. The
therapist read the scenario into the tape recorder slowly to allow Susan time
to visualize the scene’s distressing content. Susan practiced listening to the
tape and visualizing the scene while seated in a comfortable chair in the
therapist’s office with her eyes closed. The exposure continued until her
SUDS declined from 45 to 15 (about 15 minutes). The scene that Susan con-
fronted during her first exposure was as follows:
You think about how you have touched all sorts of things that the general
public puts their hands on. You don’t know who touched the railings, eleva-
tor buttons, public telephones, and doorknobs that you touched. Now you are
concerned about germs from these things. You can’t see or feel the germs, but
something tells you they’re there. You can just imagine the germs crawling up
your hands, your arms, your face, hair, and just spreading themselves all over
you. You feel like going to the bathroom and washing, or taking a nice shower
to make yourself feel better, but you don’t. You decide to just go with the
germy feeling. Now your thoughts turn to your family. You might bring home
some awful sickness because you touched surfaces today and didn’t wash or
clean. You could infect your family. You can just picture Brian and little
Jennifer becoming sick because of all the ill-advised things you did. Now, be-
cause you didn’t wash, your family might become sick.
Some guidelines for implementing imaginal exposure are presented

next. First, the patient should be instructed to put himself or herself “in the
scene,” rather than be an observer. That is, the scene should be imagined as
if it were happening to them. Second, the scenes should include response
prevention. For example, Susan imagined herself resisting the urge to de-
contaminate. Just as in situational exposures, there should be no relief (in-

cluding imagined relief) from obsessive fear during imaginal exposure.
Similarly, the urge to distract or disengage from the induction (e.g., “I know
this isn’t really happening. I’m just listening to a tape”) must be resisted.
The therapist might continually assess the vividness of the scene to ensure
against cognitive avoidance. Finally, therapists might consider imagery
training if the patient is a “poor imager.” Imagery training involves in-
structing the patient to practice imagining scenes that tap into all five
senses; for example, imagining sitting by an open window through which
the sun is shining and a gentle breeze blowing. The patient is asked to feel
the warmth of the sun on his or her face, the breeze gently blowing across
his or her forehead, and to hear the sounds of birds and of cars passing by.
Out the window, a man can be seen cutting the grass, which smells of the
fragrance of cut grass. The patient then imagines taking a sip of apple juice
and is struck by the taste of the cool drink. Imagery training continues until
the patient reports imagining the scene vividly.
Augmenting Exposure with Cognitive Interventions
The therapist takes an active role in facilitating cognitive change during ex-
posure. In other words, one does not simply sit and wait passively for habit-
uation to occur. Instead, cognitive interventions should be used to help the
patient challenge problematic beliefs about the feared consequences rele-
vant to the current exposure task. The therapist should be sure to reinforce
the patient’s decision to face feared stimuli and the importance of adopting
habits of confronting rather than avoiding such situations. This can lead
into a discussion about risk taking and embracing acceptable, everyday
levels of uncertainty. Therapists should emphasize that the practicalities of
taking such low-level risks outweigh the consequences of trying to elimi-
nate all risk to procure an absolute guarantee of safety (which is not feasi-
ble). In other words, the aim of treatment is not to provide an absolute
guarantee of safety, but to teach the patient how to live comfortably with ac-
ceptable levels of uncertainty. Informal Socratic questioning and discus-
sions of the evidence for and against mistaken beliefs (as described in
chapter 9) are two of the most useful cognitive interventions to be deployed
in the context of exposure. Toward the end of Susan’s first exposure session,
the therapist engaged her in a Socratic discussion about changes in her anx-
iety level and dysfunctional beliefs.
Therapist: Let’s examine what you’ve done in the last hour. You touched
things that you had been avoiding because of your fear of
germs and sickness. You contaminated your face, hair, and
your personal items. You even ate food off of a contaminated
paper towel with contaminated hands. You did all of this with-
286 CHAPTER 12
out washing even once. So, you would expect your SUDS to be
very high right now, but it’s only 25 and you haven’t gotten
sick. What’s going on? How did that happen?
Susan: I guess I got used to it; and I found out this isn’t as dangerous
as I had thought.
Therapist: Exactly. Now, how would you have ever learned that if you
never did exposure?
Susan: I probably wouldn’t have learned it. I would just go on avoid-
ing and thinking they were harmful.
Therapist: That’s exactly right. When you face your obsessional fears
head on, and you resist ritualizing, your SUDS eventually goes
down and you realize your fears are probably unrealistic.
Therapists should avoid trying to convince the patient that exposure sit-
uations are “not dangerous.” This is for the patient to discover for himself
or herself through experience. Risk levels are best described as “acceptably
low” rather than “zero.” Occasionally, patients will appear as if they are
straining to obtain a guarantee of safety. This might take the form of subtle
reassurance-seeking strategies (e.g., watching the therapist’s facial expres-
sion closely). As a general rule, questions about risk in a given situation
should be answered only once. Dealing with patients who persistently
request reassurance is discussed in chapter 14.
Debriefing
At the conclusion of each exposure, the initial feared consequences and es-
timates of probability and severity are revisited and revised based on the
outcome of the exercise. Was doing the exposure as awful as had been antic-
ipated? Did the feared consequences come true? If not, how come? Susan
was surprised that her anxiety declined during ERP. She also remarked that
her fear of becoming ill from touching public surfaces had decreased. She
estimated that the likelihood of becoming ill was 10% and the severity, 25%.
These ratings were recorded on the Exposure Practice Form and discussed
in terms of the redundancy of safety-seeking rituals (i.e., if the probability
of illness is so low, rituals are unnecessary).
Sometimes anxiety does not decrease during the exposure, or the pa-
tient becomes so uncomfortable that he or she chooses to leave the situa-
tion before anxiety habituates. In such instances cognitive techniques can
be used to closely examine the patient’s thoughts and experiences. For ex-
ample, overly negative beliefs such as “treatment isn’t working” can be
processed and modified into more realistic self-statements such as “I can’t
expect to get rid of such a strong habit in one day,” or “I have to give ther-
apy a chance to work. This time my anxiety didn’t decrease, but if I keep
working at it, I am likely to succeed.” The therapist can also point out that
the patient made an effort to confront a situation or stimulus that he or she
had been avoiding, and that this is a good first step. Thus, even if the exer-
cise is unsuccessful, the patient should feel as if something was gained by
attempting exposure.
HOMEWORK EXPOSURE
Assigning Homework Practice
Just as learning to be a good musician or athlete requires practice between

lessons, a person with OCD must practice exposure and response preven-
tion between treatment sessions to achieve lasting improvement. Even if
the in-session exposure goes extremely well, it must be followed by re-
peated practice in the natural environment until the feared situation
poses no difficulty. Therefore, at the end of each exposure session, a home-
work task is assigned (I often substitute the term practice in place of home-
work because many patients struggle through school and do not feel
inspired by having to complete more homework assignments). The ar-
rangement of practice assignments should be deliberate (as opposed to
haphazardly chosen) and collaborative. Early in treatment, assignments
should merely include repetition of in-session exposure exercises. Later
on, homework can involve exposure to situations and stimuli not con-
fronted during the session.
The rationale for each practice assignment should be clearly specified.
This increases the patient’s ability to consolidate information learned dur-
ing the task. It also promotes adherence—patients are more likely to com-
plete exposure tasks when they understand the reasons for which they are
assigned (Abramowitz, Franklin, Zoellner, & DiBernardo, 2002). To ensure
the rationale is clear, the therapist might ask the patient to describe it in his
or her own words (Taylor & Asmundson, 2004). As treatment progresses,
the patient should be encouraged to take a more active role in designing
homework exposures (any initiative on the part of the patient should be re-
inforced). As a rule of thumb, at least 1 or 2 hours of homework exposure
practice should be prescribed per day. Patients should also be reminded to
adhere to the response prevention rules and to record any violations of the
rules on the Self-Monitoring Form (see Fig. 8.2).
Homework exposure practice is conducted in the same manner as
in-session exposure. The main differences are that the therapist is absent
and exposure is taking place in one’s typical surroundings. Patients should
therefore review the Guidelines for Effective Exposure Form (Handout
12.1) before beginning each assignment. Instructions for each exercise must
be clearly described, including how the specific task is to be performed,
288 CHAPTER 12
where, when, and for how long. Recording this information on a copy of the
Exposure Practice Form (Fig. 12.1) that is given to the patient also promotes
adherence (multiple copies will be necessary if multiple assignments are
given). The therapist then carefully reviews how the patient is to complete
the remainder of the form (e.g., identification of feared consequences, prob-
ability and severity ratings, outcome, etc.). The patient is also to keep track
of SUDS during the homework exposure and is told to discontinue the exer-
cise after a specified amount of time or when the SUDS level declines
greater than 50% or 60% from baseline. Susan’s therapist presented the fol-
lowing homework instructions at the end of the first session. Note how
Susan was involved in the planning of the assignment:
Therapist: The next step is for you to practice doing exposure on your
own and in familiar settings. So, each day between now and
our next session, I would like you to contaminate yourself by
touching railings, door handles, and the like—just as we did in
today’s session. I also want you to practice contaminating your
home with these germs. You can use paper towels to collect the
contamination; then, you should bring the paper towels home
and contaminate things that you would normally avoid. So,
tell me, where should you spread the germs in your house?
Susan: I guess I should get them in my car, the bedrooms, the furni-
ture, and the kitchen. That’s where I’d be most concerned
about having germs.
Therapist: Good. I want you to repeat this practice every day until our
next session. You should also keep the contaminated paper
towels with you at all times to show yourself that you don’t
need to avoid contamination to feel OK. Also, you must refrain
from washing and cleaning, except for the one shower as we
agreed. Your job is to practice feeling contaminated all the time
so that you eventually realize that you don’t have to be con-
cerned with these thoughts and feelings. That means if you
slip up and wash or clean, you must recontaminate with your
paper towels immediately afterwards. You must also record
the ritual on your self-monitoring form. Remember that you
have Steve to help you out if you have trouble resisting urges
to ritualize. Do you have any questions about your practice?
Susan: No. I know what I have to do.
After the first exposure session, the therapist gave Susan several copies
of the Exposure Practice Form with the following specific assignment writ-
ten in Item 1: “Contaminate yourself and your home with germs from pub-
lic surfaces; listen to tape about germs and illness.” Instructions for
completing the rest of the form were reviewed. Imaginal exposure practice
should be conducted in a quiet atmosphere and when alone and alert. Bed-
time is not a good time for imaginal exposure because of the risk of falling
asleep. Susan was also taught how to complete the various items on the
form and instructed to monitor and record her SUDS every 10 minutes dur-
ing each day’s exposure practice. To reinforce the importance of completing
the assignments, the therapist said that the next session would begin with a
review of the completed practice forms. The session ended with Susan and
the therapist looking at the fear hierarchy and agreeing on the situation to
be confronted for exposure during the next session.
Checking Homework Assignments
It is imperative that the therapist makes a point of reviewing the patient’s

self-monitoring record and homework exposure practice forms at the be-
ginning of each session. This verifies that these important assignments
have been completed and sends the message that working on OCD be-
tween sessions is a significant part of treatment that the therapist takes seri-
ously. Reviewing the self-monitoring form also allows the therapist access
to information about difficult situations in which the patient was unable to
resist safety-seeking behaviors. Such situations can be incorporated in sub-
sequent exposure sessions. Particular attention should be paid to making
sure that adequate habituation occurred during homework exposure, and
that the patient was able to consolidate new information about the feared
stimulus and about the usefulness (or uselessness) of safety behaviors. Ver-
bal reinforcement (appropriate praise) for successfully completed home-
work should be given liberally. Instances in which homework was
attempted but habituation did not occur can be labeled as common (but
temporary) outcomes when trying to change long-standing habits. Nor-
malizing the failure to habituate places the blame on technical factors
rather than on the patient or the therapy itself. A detailed analysis of failed
exposures should be undertaken to determine whether or not the exercise
was performed correctly. If the patient did not attempt the assigned prac-
tice at all, the therapist should problem solve and help the patient complete
the task before moving on to more difficult hierarchy items. The manage-
ment of chronic adherence problems is discussed in chapter 14.
CONDUCTING EXPOSURE
FOR DIFFERENT SYMPTOM DIMENSIONS
Using the treatment session just described as a general outline, this sec-
tion describes the nuances of tailoring exposure for each of the OCD
290 CHAPTER 12
symptom dimensions. Stylistic issues and common procedural varia-

tions, such as conducting exposure outside the office, are discussed in
later sections of this chapter.
Contamination
The preceding section illustrates exposure for contamination symptoms

where the patient articulates feared consequences such as becoming ill or
causing others to become ill. The exposure session proceeds similarly to
one that would be conducted for specific phobia. For individuals who are
fearful of spreading contamination, we might have them shake hands
with “innocent victims,” or surreptitiously taint objects in other people’s
offices. For those concerned with floor germs, we conduct entire sessions
seated on the floor (in an office or perhaps in a bathroom, depending on
the patient’s idiosyncratic concerns). For those fearful of bodily waste and
secretions, we supervise direct confrontation with such substances (or sit-
uations in which the substances might be present; e.g., using the toilet
without washing afterward, dirty towels at the gym locker-room). The
aim of helping patients to repeatedly practice taking such “risks” is not to
permanently alter their hygiene practices. Instead, the desired goal is be-
lief change. Through these exercises the patient learns that the feared con-
sequences (i.e., illness) are far less likely than he or she had anticipated.
Patients also discover that precautions such as excessive ritualized wash-
ing, cleaning, and other safety behaviors to prevent or remove contact
with feared contaminants are unnecessary. On occasion, patients ask
whether they must continue ERP indefinitely. We typically explain that
when treatment is successful, patients feel at greater liberty to decide how
to lead their lives without their choices being governed by obsessive fear.
That is, there will eventually be less riding on the decision to wash or not
wash one’s hands.
For the group of patients with contamination obsessions but no specific
concerns about germs or sickness, the main feared outcome of exposure is
that the sense of distress or uncleanness will persist indefinitely or be-
come unmanageable unless decontamination rituals are performed. For
such patients, exposure exercises should be framed as helping to demon-
strate that the sense of discomfort associated with contamination does not
persist indefinitely. This can employ both the habituation model and the
cognitive perspective. Indeed, habituation during ERP sessions provides
compelling evidence against the patient’s belief that distress will persist
indefinitely. This outcome is discussed to facilitate changes in expecta-
tions when contaminants are encountered in the future. Typically,
imaginal exposure is not a necessary component of treatment for patients
with this presentation of contamination symptoms.
Harming
Exposure for harming symptoms is often more complex than for contami-
nation symptoms. First, the situations and stimuli that trigger obsessions
about responsibility for harm or mistakes vary tremendously and are
highly patient specific. The therapist therefore has a greater challenge in
matching exposure tasks to the exact nature of the patient’s fear. Second,
obsessional fear is typically associated with uncertainty and thoughts of di-
sastrous consequences that are evoked by certain situations, rather than by
palpable external stimuli such as urine or pesticides as in contamination
symptoms. This necessitates the use of secondary imaginal exposure (along
with situational exposure) to promote habituation to, and modification of
beliefs about, the salient obsessional thoughts and doubts.
Often, evocation of harming obsessions can be achieved in the clinic, such
as by having the patient write unlucky numbers or complete important pa-
perwork while being distracted. In other cases, it is necessary to conduct situ-
ational exposure outside the office. Examples include accompanying the
patient to his or her home to practice leaving appliances plugged in, driving
to confront fears of hitting pedestrians, and going to public places to put
“dangerous” objects (e.g., glass, pins) where people walk. Whether con-
ducted in or out of the office, it is essential to systematically expose the pa-
tient to his or her thoughts and doubts of being responsible for harm (or
uncertainty regarding whether such harm will occur) as evoked by the situa-
tional exposure. Cognitive interventions are used in the context of exposure
to help the patient think differently about risk and uncertainty, and to correct
dysfunctional and catastrophic interpretations of the presence and meaning
of obsessive doubts about feared consequences.
When arranging situational exposures for harming obsessions, the
therapist must ensure that the patient feels responsible for any possible
negative consequences of exposure. For example, someone with fears of
hitting pedestrians while driving might feel more comfortable when ac-
companied by the therapist on a driving exposure because, in the words of
one patient, the therapist “would never let a hit-and-run accident hap-
pen.” The therapist should be attentive to such details and ask whether
conducting the driving exposure unsupervised would evoke more dis-
tress than if the task was supervised. On a related note, some exposures to
situations in which there is a fear of harm could be compromised if the pa-
tient remains for an extended period of time. For example, staying in the
house after plugging in the television or turning on the stove is inherently
a check that no fire has started. Therefore, when situational exposure
evokes uncertainty about negative outcomes, necessary precautions
should be taken to ensure that no de facto reassurance seeking occurs. Sec-
ondary imaginal exposure to the feared outcomes (including not knowing
292 CHAPTER 12
for sure if they will occur [or already have occurred]) should be com-
menced to prolong the exposure exercise.
Susan’s main harming symptoms included the fear of assigning incor-
rect grades to her students, which she feared would ruin their academic ca-
reers. In response to these obsessions, she excessively checked that her
grading was “fair and accurate” and that she had correctly recorded her as-
signed grades into her computer spreadsheet. Susan and the therapist had
planned for Susan to grade papers during the second exposure session. Af-
ter reviewing Susan’s self-monitoring forms and her progress with be-
tween-session (homework) exposure practice, the therapist described how
the session would proceed:
Therapist: I see that you brought in some papers to grade for our expo-
sure today as we had planned. Tell me all about what hap-
pens when you try to grade papers.
Susan: I brought in spelling tests to grade. They are one of the biggest
problems. First, it has to be absolutely quiet or else I’m afraid
I will mess up. If I’m distracted, I have to start over. Then, I
have to carefully go over each student’s paper and compare
his or her answers to the answer key. I usually review the pa-
per two or three times to be sure I didn’t grade anything in-
correctly. Sometimes, I’ll wonder whether I made a mistake
on a certain student’s paper and have to go back through the
pile to check again. When it’s really bad, I get Steve to recheck
my grading just to make sure there are no mistakes. Then, en-
tering the grades into the computer is another story. I have to
check and recheck to make sure I didn’t switch students’
grades by accident, and sometimes have to re-enter all the
grades to be sure there are no mistakes. Sometimes I have to
do this a few times until I feel satisfied that it’s correct. The
whole thing can take a few hours when I only have about 25
students in the class.
Therapist: Well, we’re going to help you with overcoming your urge to
check. How long should it take you to grade each test?
Susan: About a minute each.
Therapist: And I’m curious about how often you find that you’ve actu-
ally made a mistake.
Susan: I never find mistakes; but I could make them. And they would
have terrible effects.
Therapist: Interesting that you never find errors, though. What does that
tell you?
Susan: That I probably won’t make any mistakes.
Therapist: I suppose you’re right … probably not. So, today, I’d like you to
sit at my desk and grade these papers without checking.
You’re allowed to spend 1 minute on each paper, and I’ll be
timing you. After you’re finished each paper, you must put
them back into your bag and not recheck them. Then, you will
enter the grades into the spreadsheet and put the laptop com-
puter away without checking. The other thing is that I’m going
to turn on this radio and sit in the corner reading some journal
articles. So, I won’t be there to catch any mistakes. OK?
Susan: I don’t know. I think we should do it without the radio. I’m
afraid I’ll get distracted and make a mistake.
Therapist: Well, if we leave the radio off and you start to feel more and
more comfortable with grading the papers, will you think
that’s because you’re unlikely to make mistakes, or because
you’re not being distracted?
Susan: Probably because I’m not being distracted.
Therapist: That’s right. But in order to reduce your fear, you need to
learn that it’s not the lack of distraction that keeps you from
making mistakes; it’s that you’re less likely to make them
than you think. So, I’m afraid the exercise wouldn’t be as
helpful of we kept the radio off. Do you see what I mean?
How about giving it a try my way?
Susan: OK, I’ll try it.
After discussing feared consequences (making mistakes in grading, ru-

ining academic careers) and the initial probability and severity estimates
(80% and 65%, respectively), Susan gave an initial SUDS rating (78) and be-
gan grading each spelling test while the radio played fairly loud rock mu-
sic. She graded each test within the 1 minute allotted to her. Every 5 minutes
the therapist asked for a SUDS rating. After 20 minutes, when all tests had
been graded, Susan’s SUDS was 40 and she was visibly less distraught as
compared to when the exercise began. Next, she was instructed to enter the
test grades into her spreadsheet program on her laptop computer without
double-checking for accuracy. Her SUDS increased noticeably (75), as did
her urges to check. The therapist employed cognitive strategies to help
Susan manage her strong ritualistic urges.
Susan: I really need to recheck the computer grades. I know it’s a rit-
ual but that’s the only permanent record of the test grades
once I hand them back to the students. If it’s wrong, some-
thing terrible could happen when I have to turn in final
grades for report cards.
294 CHAPTER 12
Therapist: I suppose you are right about that. There is a possibility of er-
ror. However, what do you think you would find if you went
back and checked? What do you usually find when you do
checking rituals?
Susan: That everything is OK. There are no mistakes.
Therapist: Right … you know what you’d find if you checked. So, check-
ing is merely a habit to give you reassurance. We need to break
this habit because it only leads to a vicious cycle as we have
talked about. Think back to our discussion of intrusive
thoughts and how people with OCD react to them. If someone
had intrusive thoughts about making unlikely mistakes but
interprets those thoughts as very significant and meaningful,
how would the person feel and what would they probably do?
Susan: They’d feel anxious and check to make sure there is no mis-
take.
Therapist: Right. Do you see how you’re doing this? [Susan nods in
agreement] Now, what is a more helpful way of dealing with
these intrusive thoughts? What’s a more realistic interpreta-
tion that leads to less checking?
Susan: That the thoughts are just thoughts. They don’t mean anything.
This dialogue led to a secondary imaginal exposure that was introduced

as a way of weakening the pattern of becoming anxious and checking in re-
sponse to senseless obsessional doubts. Susan was instructed to describe a
scene in which she makes a grading error, resulting in a student failing and
eventually not being accepted to college. The patient and therapist derived
an imaginal exposure script together and made it as generic as possible
(this way, the scene could be used along with multiple exposures to similar
situations). The final product was as follows:
In rushing through grading the papers, I might have mistakenly marked

three answers as incorrect on a particular student’s paper, when he or she
actually had them correct. The radio was playing, I was distracted, and I
was grading quickly. I didn’t check the papers either. So, if I made this mis-
take, I didn’t catch it. Then, I entered all the grades into the computer. So, if
I did make a grading mistake, the students’ final average for the year could
be bumped down from what they really deserved. And it’s my fault. I
could have checked and avoided this problem. As a result, some of my stu-
dents might be placed in a lower level English class next year and might
not do well because the less demanding teachers usually teach the lower
level classes in middle school. They might end up not doing well in English
all through middle and high school and then not get into any good colleges
because of this. It would be entirely my fault. If I could just check the pa-
pers again … if I could just be sure that all the papers are graded correctly I
would know that everyone would be OK. Because I am not going to check,
it is possible that my students’ future is up in the air, and it could be my
fault if they end up failures in life. I’ll never know because I am resisting
checking this time.
Susan recorded the scene onto a loop tape by reading it aloud. Then, the
tape was replayed with instructions for Susan not to check, neutralize, or
do anything else to gain reassurance. Instead, she was encouraged to allow
the thoughts and uncertainty to linger in her mind and consider the
thoughts as normal, senseless intrusions. Susan’s SUDS decreased after
about 20 minutes of listening to the tape. A discussion about Susan’s ability
to manage uncertainty and her tendency to misinterpret intrusive thoughts
followed the exposure. For homework practice, she was instructed to grade
another set of papers and enter them into the computer while listening to
the radio or television, and then to complete imaginal exposure to the loop
tape until her anxiety habituated. No checking was permitted and Susan
was reminded to record any instance of checking on her self-monitoring
form. She was also instructed to hand back the papers to students without
any checking. Throughout the rest of treatment, Susan was instructed to
grade all papers using the techniques practiced in the session. She was also
informed that in-session time could be used for additional practice if she
experienced difficulty grading on her own.

The aim of exposure for this dimension is to weaken the connection be-
tween repugnant obsessional thoughts and anxiety. This occurs through
habituation and by helping the patient develop a new, nonthreatening
understanding of intrusive obsessional thoughts, impulses, images, and
ideas (e.g., as “brain farts”). Therefore, the main exposure technique is
primary imaginal exposure wherein the patient repeatedly practices
thinking the intrusive, unwanted thought. As discussed in chapter 10,
this technique is akin to situational exposure, except that the stimuli are
thoughts rather than external cues. Loop tapes provide an excellent
means of prolonging confrontation with thoughts because the stimulus
is presented without giving the patient an opportunity to neutralize or
suppress. Naturally, if there are particular situations or stimuli in the en-
vironment that the patient avoids, these should be incorporated as situa-
tional exposures as well. For example, a female patient who avoids
looking at attractive women for fear of thinking lesbian thoughts might
practice looking though fashion magazines (situational exposure) and
purposely thinking about lesbianism. If necessary, secondary imaginal
exposure to feared consequences should also be incorporated into the
loop tape. For example, if the fear exists, this patient should also be ex-
posed to uncertainty regarding whether she will become a lesbian be-
cause of all the thoughts she has.
296 CHAPTER 12
During the third exposure session, Susan confronted unwanted

thoughts of stabbing her baby girl, Jennifer. Jennifer was brought to the ap-
pointment, as had been prearranged. The session began with the therapist
eliciting the details of the obsessional thought, Susan’s appraisals of the
thought, and her responses. Note how the therapist helped Susan to see
how her appraisals of her obsessions influence her use of safety behaviors:
Therapist: Can you describe the details of the thoughts you have about
stabbing Jennifer?
Susan: It’s difficult to say … If I’m using any sharp object … a kitchen
knife, the scissors, I get the thought of stabbing her. I think
about how easy it would be. She’s just a baby and wouldn’t
know how to stop me. I feel so bad for thinking about how
easily I could kill her.
Therapist: I realize those are upsetting images for you. When they come
to mind, how do you interpret them? What do you think they
mean?
Susan: I must be a terrible person for having those thoughts. I mean,
what kind of person thinks about killing their own child? I
feel very guilty.
Therapist: How much do you worry about acting on the thoughts?
Susan: I don’t want to—I love her with all my heart. But I some-
times wonder whether I might just snap and do something
terrible since I think about it so much. You hear those stories
of people who snap and kill their kids from time to time.
What if I’m next?
Therapist: Yes, I am aware of those stories. That’s very tragic. One of the
things we should do is look more closely at the evidence regard-
ing how likely you are to hurt Jennifer. But first, let’s examine
your interpretations of these thoughts. If you’re telling yourself
the thoughts mean you’re a terrible person and that they could
make you do terrible things, how are you going to feel?
Susan: Scared.
Therapist: That’s right. And how will you respond to the thoughts?
Susan: I would try to make them go away, which is basically what I
do.
Therapist: That’s right. As we have talked about before, your interpreta-
tions dictate your responses. But how well do your strategies
for dealing with the thoughts work?
Susan: Not too well, I guess. I mean, I keep having the thoughts.
Therapist: That’s right. Remember when we talked about trying to sup-
press thoughts of a white bear? People are not very good at
stopping their own thoughts. [pauses] The real question is,
“Do the thoughts about harming Jennifer really mean what

you think they do?” Maybe you don’t need to spend all of this
time and energy worrying and trying to suppress them. What
did we learn a few sessions ago when we were talking about
who has senseless nasty thoughts?
Susan: Well, everyone has them from time to time. You said they’re
normal. You said you even have bad thoughts sometimes.
Therapist: That’s right, I sure do. Real bad ones, sometimes … as do
most people. But I don’t get worried when those thoughts
come up. Why do you think that is?
Susan: Because you know they are just normal thoughts.
Therapist: So, if you interpreted your nasty thoughts about Jennifer as
normal thoughts that everyone has, how would you feel
when they come to mind, and what would you do?
Susan: I guess I’d feel less afraid. I wouldn’t have to avoid situations
where they came up, and I wouldn’t feel like I always have to
try to push them out of my mind.
Therapist: Yeah, that’s right. If you knew in your gut that the thoughts
are meaningless, insignificant, and not at all dangerous, you
wouldn’t worry whether they come to mind or not. It
wouldn’t be an issue. And you’d be less preoccupied with
them, so you would probably notice them less often. The ex-
ercises we will do today are designed to help you change
your perception of these thoughts and help you develop
more helpful ways of responding to them.
The therapist then introduced the exposure task that had been planned
for the third session and asked Susan to generate evidence for and against
her belief that she would act on her intrusive thoughts to stab Jennifer. The
evidence for and against this belief was recorded in tabular format on a
whiteboard as shown in Fig. 12.2. After a discussion that involved a review
of the cognitive-behavioral model of obsessions and a closer look at the dif-
ferences between people with OCD and those with antisocial personality or
psychosis, Susan was able to recognize that she was unlikely to do any
harm (her likelihood rating was 10%).
Susan was told the exposure exercise would begin by working with the
therapist to compose a loop tape containing a vivid description of the unac-
ceptable stabbing thought. Next, she would listen to the tape while holding
Jennifer. Then, a knife would be placed next to Susan as she held the child
and listened to the tape. Finally, Susan would hold the knife and use it to
slice food while continuing to think about stabbing Jennifer. Susan was in-
structed to refrain from any forms of thought suppression or neutralizing.
Instead, she was told to “go with” the unwanted thoughts, and let them
298 CHAPTER 12
FIG. 12.2. Evidence for and against Susan's belief..
“hang out in her brain.” She was also permitted to consider the evidence
generated from the CT exercise (which remained for her to see on the
whiteboard). Susan was told this exposure task would help her in two
ways: First, it would help her test (and disconfirm) the validity of her belief
that thinking about stabbing Jennifer would lead to losing control and act-
ing violently. Second, it would help her see that she can think this
unwanted thought without remaining highly anxious.
Initially, Susan, like many patients, balked at purposely inducing her
upsetting obsessional thoughts:
Susan: I don’t know if I should make myself think about stabbing

Jennifer. It’s really not a good idea to think those kinds of
things just for the sake of doing it.
Therapist: But I think there’s a good reason for doing this exercise. It will
reduce your fear of the thoughts. Just like with the exposures
you’ve done over the last few sessions, this will help you see
that your violent thoughts are not as dangerous as you think.
Remember how we talked about changing your interpreta-

tion of these thoughts? This exercise is designed to help you
do just that. We need to correct your pattern of responding
maladaptively to this thought.
Susan: I’m not sure I can do it.
Therapist: Actually, I know you can do it. I know this because you say
that you spend hours thinking these very thoughts every day.
So, I’m not asking you to think about anything you’re not al-
ready thinking about, right? The difference is that you are go-
ing to practice using more helpful strategies for dealing with
the thoughts. When you confront the thoughts today, you
will give yourself the chance to see how harmless they really
are. Remember, these are normal thoughts; the exposure task
is a way of helping you prove to yourself that you don’t have
to worry so much. So, what do you say?
After this discussion, Susan agreed to begin the exposure. Her initial
SUDS rating was 80. The content of the imaginal exposure loop tape, as gen-
erated by Susan and the therapist, was as follows:
You are thinking about your 3-month-old baby, Jennifer, who you love so
much. She’s so sweet and innocent. She’s small and cuddly. You and Steve are
so careful not to let anything happen to her. She’s a wonderful little baby.
Now, you are thinking about stabbing her … What an awful thing that would
be. You have an image of losing self-control and just slicing her neck with a
knife. Or, you could stab her in the stomach, over and over. There would be
blood gushing out of her body … she’d be kicking and screaming with pain …
you can just hear it … she would probably die of the wounds you inflicted.
And she never had a chance … you’re just too strong for a helpless infant to
defend herself against. As you look at her cute little face, you think about how
there’s really nothing stopping you from doing this … just your own judg-
ment … You allow yourself to think about stabbing Jennifer. You imagine viv-
idly what it would feel like … You try to picture how would it feel …? How
would it look …? What would your husband say …? And what would hap-
pen afterwards with the police …? You let yourself just dwell on these
thoughts of stabbing Jennifer. Keep the images in your mind as vividly as you
can. Stabbing Jennifer …
Susan successfully listened to the tape while holding Jennifer, and after
15 minutes her SUDS was reduced to 30. In fact, she reported becoming
“bored” with the thought—which is exactly the intention (boredom is in-
compatible with feeling anxious). At that point, the knife was introduced.
At first, it was placed next to Susan on a table. Then Susan held the knife
while also holding Jennifer. The therapist periodically praised Susan for
her bravery and reminded her not to do any mental rituals or thought sup-
pression. After an initial increase to 70, her SUDS dropped back to 45. At the
300 CHAPTER 12
40-minute mark of the session, the therapist took out an apple and a cutting
board. Susan was asked to put Jennifer on the floor and slowly slice the ap-
ple right next to her, while continuing to listen to the loop tape. Susan suc-
cessfully completed the task without an increase in SUDS. The therapist
inquired whether his leaving the room would increase Susan’s fear of act-
ing on the intrusive thoughts. Susan said she had considered that the thera-
pist would intervene if she had started to stab her daughter. Therefore, the
therapist left the office. From another extension, he telephoned Susan every
5 minutes to obtain a SUDS rating and reinforce Susan’s hard work. After 60
minutes, Susan’s SUDS had decreased to 25 and she appeared visibly more
comfortable. At that point, the exercise was terminated.
Debriefing followed along the lines of previous exposures. Using a So-
cratic style, the therapist asked Susan what she had learned from the exer-
cise. Susan reported believing quite strongly that she was unlikely to act on
her thoughts. She was quite surprised that her distress had decreased so
dramatically even without safety behaviors. The therapist reminded Susan
to use the same approach when unwanted intrusive thoughts came to mind
at home. Accordingly, she was instructed to practice the same exercise at
least once each day between appointments and to record her progress using
the appropriate forms.
It is vital that the therapist exudes confidence in the cognitive-behavioral
model when discussing objectionable thoughts and when suggesting (and
implementing) exposure exercises. Demonstrating conviction that such
thoughts are ordinary and innocuous, and that exposure is likely to be help-
ful, probably increases the odds that the patient will agree to confront these
stimuli. After completing the exposure exercise, Susan mentioned that the
therapist’s very eagerness to have her think violent thoughts while holding
a knife in one hand and Jennifer in the other arm helped to convince her that
her fears were unrealistic.
Incompleteness
Although Susan did not display obsessions and rituals associated with in-
completeness, a discussion of how to conduct exposure sessions for these
types of symptoms is essential because many patients present with such
concerns. As with the contamination subtype, patients with incomplete-
ness OCD symptoms may or may not articulate explicit fears of harm.
When the sense of inexactness, disorder, imperfection, or asymmetry
evokes obsessional fears of responsibility for disasters (e.g., “Mother will
be injured if I do not put on my clothes the ‘correct’ way”), situational expo-
sure to external cues should be conducted, accompanied by secondary
imaginal exposure to the feared consequences. In practice, such exposures
are similar to those typically conducted for the harming symptom dimen-
sion discussed previously. Cognitive interventions are used to modify in-
tolerance of uncertainty, excessive responsibility, and the misinterpre-

tations of intrusive thoughts about disasters. Patients must, of course, be re-
minded to refrain from safety-seeking behaviors such as checking and re-
peating rituals, and reassurance seeking. As an example, one patient,
concerned that stepping on sidewalk cracks would cause harm to his rela-
tives, practiced purposely stepping on cracks and confronting thoughts of
his parents being horribly injured. Another patient, who feared bad luck
from odd numbers, practiced confronting odd numbers wherever possible
(e.g., ordering food that cost $7.00, choosing to be the fifth person in the
line) and wishing for bad luck to occur.
Exposure for incompleteness symptoms without fears of causing harm
is focused on desensitizing the patient to the subjective sense of incom-
pleteness (i.e., habituation). From a cognitive perspective, repeated and
prolonged exposure helps the patient develop a more realistic appraisal of
these feelings. Instead of requiring an immediate response to prevent
ever-increasing subjective distress, the patient learns that the distress asso-
ciated with these feelings fades over time, thereby rendering compulsive
rituals unnecessary. Verbal cognitive techniques can be used to highlight
patients’ mistaken appraisal of “not just right” feelings as dangerous or
likely to persist indefinitely if rituals are not completed. Imaginal exposure
is typically not included in the treatment of such symptoms.
CONFRONTING THE GREATEST FEARS
Some words are in order regarding helping patients (across symptom di-
mensions) to confront their most feared stimuli. First, exposures to the
most difficult hierarchy items should be conducted during the middle
third of the treatment program. This way, plenty of therapy time remains
to sort out any unforeseen difficulties that arise while working up the hi-
erarchy or when attempting to confront the most difficult stimuli. Second,
although for many patients success with early exercises translates to rela-
tively straightforward high- level exposures, for some individuals the
process is anything but routine. Such patients require no small dose of en-
couragement and praise for their efforts. The therapist should, on the one
hand, take a firm stand that such exposures are a necessary part of therapy
as agreed to during treatment planning, yet on the other hand, convey
sensitivity and understanding that these tasks are likely to evoke high
SUDS levels. Patients can be reminded that distress during exposure is a
temporary side effect. It might be motivational for the therapist to model
difficult exposures before they are attempted by the patient. A third, and
related, point is to encourage the liberal use of cognitive interventions. In-
formal discussions of evidence collected from previous exposure exer-
cises, acceptable versus unacceptable risks, and learning to tolerate
uncertainty are often quite useful.
302 CHAPTER 12
Another benefit of having the patient face the most difficult exposure situ-
ations relatively early in therapy is that this affords ample time for confront-
ing the most feared stimuli in varied contexts and independently.
Experimental research (e.g., Bouton, 2002) suggests that fear reduction tends
to be most complete and long-lasting if the patient conducts exposure (situa-
tional and imaginal) in different settings. For example, suppose a patient
with blasphemous obsessional thoughts has become relatively comfortable
facing such thoughts in the therapist’s office. He might next practice evoking
these obsessions in situations that he has been avoiding, but that regularly
trigger the obsession, such as in a place of worship or cemetery. A different
patient who fears responsibility for car accidents might practice driving on
roads she has been avoiding, and with greater distractions (e.g., loud music,
talking on a cell phone) in the car. The assessment of each patient’s idiosyn-
cratic beliefs and avoidance patterns will be especially important for deter-
mining in what specific contexts exposure needs to be done.
LATER EXPOSURE SESSIONS
As a rule, each hierarchy item is repeatedly confronted (e.g., at least daily)

until it evokes a minimal level of distress or urge to ritualize. After exposure
to the most distressing hierarchy items evoke minimal distress, the remain-
ing therapy sessions and homework assignments involve confrontation
with various items in a range of contexts where they might be avoided or
still cause difficulty. This serves to generalize the effects of treatment. For
example, one patient—a real estate agent—was afraid of leaving lights and
appliances on that might cause a fire. One of his exposures had involved
turning the lights and appliances in his home on and off quickly, and then
leaving the premises and imagining the possibility of a fire. During later
sessions, this patient practiced similar exercises in the homes he was show-
ing for sale. Another patient with obsessional fears of yelling obscenities
and insults practiced “tempting himself” to verbalize (e.g., by thinking of
or whispering to himself) such epithets during later sessions in various
places he was still avoiding (e.g., libraries, places of worship, among peo-
ple of different races). Home (or workplace) visits can also occur during the
later treatment sessions. For patients with contamination symptoms who
are fearful of soiling their personal living or work spaces, the therapist can
oversee the spreading of contaminants already confronted during earlier
sessions into these hallowed areas.
STYLISTIC CONSIDERATIONS
Conducting exposure-based therapy is at once a science and an art. As dis-

cussed previously, the treatment is based firmly on well-understood prin-
ciples of normal human cognition and behavior. Moreover, substantial

(and consistent) research evidence indicates that therapeutic exposure
causes significant reductions in pathological fear. Less well studied, but
probably equally important, are the technical aspects of implementing ex-
posure therapy. I have already discussed how cognitive interventions can
be used to “tenderize” strongly held dysfunctional beliefs and encourage
patients to persist with treatment. In this section, I describe a number of
additional tactics therapists can employ to help patients get the most out
of the treatment program.
Building on Early Successes
Many patients experience higher levels of anticipatory anxiety as the diffi-

culty level of exposures increases. To encourage patients to confront more
challenging situations, therapists should heed, rather than disregard, the
patient’s distress, yet affirm the importance of choosing to persist with
these exercises. One strategy the therapist can use is to remind patients of
the outcomes of previous successful exposure tasks. The following is an ex-
ample of how Socratic questioning was used to guide Susan toward the
conclusion that conducting a higher level exposure task would likely have
the same consequences as previous tasks.
Susan: I’m not sure I’m ready to touch garbage cans yet. It seems like
it’s going to be very hard to do this knowing I can’t wash my
hands afterwards.
Therapist: I see. Is there something in particular that you’re worried
about?
Susan: I’m just very scared to do it. I almost didn’t come today be-
cause I knew we were going to do this.
Therapist: Well, I’m glad you came. It sounds like this is an especially
tough one for you. Hmmm. I remember how anxious you
were before you practiced getting your hands contaminated
from public door handles. But what happened once you got
started?
Susan: My SUDS went down after a little while.
Therapist: Right. It took some time, but you stuck it out and saw that you
felt better after a while. And how sick did you become, or
make your family?
Susan: No one got sick. That’s true.
Therapist: Right. Actually, all of the exposures you’ve done have re-
duced your anxiety, and none have resulted in the negative
consequences that you worried about. So, what makes you
think this one will be any different?
304 CHAPTER 12
Susan: I don’t know. I guess I should give it a try and see.
Refining the Fear Hierarchy

When the therapist adheres to the collaboratively developed exposure
plan, it reinforces the systematic nature of the therapy and places clear ex-
pectations on the patient. This consistency probably helps to cultivate trust
and confidence in the therapist and favors a continued commitment to the
therapy. Nevertheless, important details of the patient’s obsessional fears
are sometimes not revealed until well into the exposure phase of treatment.
Therefore, in addition to progression up the fear hierarchy as planned, ex-
posure sessions should involve continued assessment and course correc-
tion depending on the phenomenology that is unearthed as treatment
progresses (Kozak & Foa, 1997).
One circumstance in which it becomes necessary to adjust the expo-
sure hierarchy is when the patient refuses to confront a particular stimu-
lus because of extreme anxiety. For example, Susan and her therapist had
planned for Susan to be exposed to a public bathroom during the sev-
enth exposure session. However, when the therapist suggested that the
exercise take place in a local fast food restaurant’s bathroom, Susan ex-
pressed profound anxiety and put her foot down, saying she would not
do this task. Instead of demanding that Susan confront this bathroom,
the therapist suggested that she spend the seventh session confronting
an “easier” public bathroom to help her prepare for eventually facing the
fast food bathroom during a later session. This use of transitional expo-
sure is described here.
Susan: I can’t do it. I can’t make myself go into a fast food bathroom.
Therapist: I understand this is a difficult exposure for you, but we did
agree to practice this today. What in particular would be so
bad for you about going to a fast food bathroom?
Susan: I know I agreed to do this, but fast food bathrooms are so
dirty. No one ever cleans them and all kinds of people use
them. That would be the worst possible bathroom for me.
Therapist: I see. If going to a fast food bathroom is the most difficult per-
haps you could pick a less difficult public restroom where
you would be willing to practice today. Do you have any sug-
gestions?
Susan: I guess I could try going to a hotel lobby bathroom.
Therapist: OK. And why would that be easier for you?
Susan: Well, they’re usually better cleaned. I guess I won’t be as
grossed out.
Therapist: Well, it’s not exactly what we had planned, but it is a public
restroom. So, I think that’s a good choice for today. But we
need to agree that next session you will expose yourself to a

bathroom in a fast food restaurant. What we’re doing today
will help to prepare you for doing that. OK?
Susan: OK. Thanks for taking it easy on me today.
Therapist: Well, the most important thing is that you face your fears. If it
takes a little longer than we had originally planned, it’s OK.
Conducting Exposures Outside of the Office

The idiosyncratic obsessional fears and avoidance patterns of OCD pa-
tients often require that exposure practice be conducted outside the thera-
pist’s office. Examples include visiting public bathrooms, funeral homes,
the pesticide aisle in grocery stores, areas of town where “contaminated”
people might be found, churches or synagogues, driving on highways or
parking ramps, and walking through parks where dog feces may be found.
Some patients’ symptoms require that exposure be conducted in their own
home due to fears of contamination from certain rooms or concerns about
causing fires. It is therefore advantageous for therapists to have the flexibil-
ity of being able to leave the office to accompany patients on such field trips.
For the most part, exposures in public places such as restaurants,
stores, and cemeteries can be conducted surreptitiously and with ano-
nymity. Plans for how the exercise will be proceed should be discussed in
private beforehand so that overt directives can be kept to a minimum dur-
ing the task. Necessary behaviors such as touching or rearranging items,
or leaving them on the floor, should be performed discreetly so as not to
draw undue attention. Prolonged exposure and amplification can be ac-
complished by holding an item (e.g., a bottle of pesticide) while continu-
ing to browse or by placing it in a shopping cart and picking it up
periodically. Unforeseen difficulties such as unexpectedly high anxiety or
persistent sales clerks can be managed by leaving the scene, regrouping,
and returning at a later time (Steketee, 1993).
In other situations where there might be less anonymity it is wise to ask
permission and provide advance warning when contemplating out-
of-the-office exposure. On occasion, the other party will want an explana-
tion of the therapeutic activity, and as a rule (as long as the patient con-
sents), honesty is the best policy. For example, one patient treated in our
clinic was afraid of contamination from dead bodies and required exposure
to a funeral home. When planning this exercise, the therapist telephoned a
local funeral home to inquire about a visit. The director, perhaps thinking
he was getting a new client, asked about the purpose of the appointment.
Fortunately, the patient had given the therapist consent to disclose the ac-
tual nature of the proposed visit. After a brief description of the purpose
and procedures of exposure therapy, the director was happy to give the
therapist and patient a tour of the funeral home.
306 CHAPTER 12
We find that many patients are willing to go out in public with their ther-
apist. Still, it is important to discuss and plan for all possible contingencies,
including a cover story and strategy for expeditiously handling awkward
encounters with friends, relatives, or others while out in public places. Lia-
bility issues are also a reality in today’s world, adding another dimension
of precaution for the therapist. For example, in our clinic, therapists are not
permitted to drive patients to exposure destinations. Thus, plans for meet-
ing at specific destinations are arranged ahead of time.
Teaching the Patient to Be His or Her Own Therapist

An early study by Emmelkamp and Kraanen (1977) found that OCD pa-
tients who completed all exposure tasks under the close supervision of
their therapist showed a slight relapse of their symptoms after ending treat-
ment, whereas those who had confronted feared stimuli on their own (i.e.,
self-controlled exposure) continued to improve. Self-controlled exposure
probably promotes autonomy and helps the patient gain confidence in his
or her ability to combat OCD symptoms whether or not the therapist is
present. Thus, after formal treatment ends, patients who have learned to
implement these skills on their own are likely to be better off than those pa-
tients who have not learned how to do this. These results highlight the im-
portance of homework exposure practice. They also insinuate that it is
therapeutic to use a fading procedure across treatment sessions. That is, al-
though close management of the initial exposure exercises is imperative,
the therapist should consider stepping back and encouraging patients to
become “their own therapist” when it is clear they have learned to effec-
tively implement the treatment techniques. This entails allowing the pa-
tient to choose (from equally fear-evoking stimuli), design, and implement
exposure tasks. The therapist, of course, maintains the role of coach and
lends his or her expert guidance during each exercise. Decisions to confront
highly anxiety-evoking stimuli are reinforced with praise, whereas avoid-
ance is followed up with questioning to assess the nature of the fear and ad-
dress the causes of avoidance.
Programmed and Lifestyle Exposure

Most people with OCD have a chronic problem, and chronic problems re-
quire constant attention over the long term. Therefore, instead of a quick
fix, CBT promotes permanent lifestyle change by helping patients make
sustainable modifications to their thinking and behavior. This involves the
patient working hard to incorporate ERP as part of day-to-day life, rather
than something to be done only when directed by the therapist. New habits
of confronting obsessional fear must be practiced in diverse situations to
promote generalization of treatment effects.
Whereas patients usually understand that response prevention entails

across-the-board abstinence from safety behaviors such as rituals, neutraliza-
tion, and assurance seeking, it may be less clear that they must also practice
avoidance prevention. That is, some patients complete their assigned exposures
and then proceed to use avoidance strategies between sessions. For example,
one patient with fears of contamination from homosexuals diligently com-
pleted the assigned homework task to visit a gay bar and subsequently re-
frained from his typical decontamination routines. However, he also avoided
wearing certain clothes and sleeping in his bed (he took to sleeping on the
couch after exposures) because of his fear of spreading contamination from the
bar. As a result, his contamination concerns remained intact.
From the first exposure session, the patient should be taught to think of
ERP as a new lifestyle that is conducive to gaining control over, rather than
being controlled by, OCD. To promote this new set of healthy habits, we
find it useful to differentiate between programmed and lifestyle exposure.
Programmed exposure includes carefully developed, hierarchy-driven exer-
cises that the patient agrees to conduct in session and under specified cir-
cumstances, at predetermined times, and in particular locations between
sessions. Lifestyle exposure, on the other hand, refers to making choices to
take advantage of additional opportunities to practice confronting rather
than avoiding obsessional fears (i.e., focus on choosing to be anxious). The
patent is encouraged to be opportunistic and to view spontaneously arising
obsessional triggers as occasions to practice ERP techniques and work on
further reducing OCD symptoms, not as situations to be avoided or en-
dured with great distress. Patients should often be reminded that every
choice they make regarding whether to confront or avoid an obsessional
cue carries weight. Each time they choose to confront such a situation with-
out using avoidance or safety behaviors, they are weakening the OCD pat-
terns. Alternatively, each time a decision is made to avoid, the OCD
patterns are strengthened. For some patients, for whom obsessional stimuli
are truly ubiquitous and rituals dominate the day, embracing ERP as a new
lifestyle may be the difference between treatment success and failure.
Using Humor
The use of humorous comments or modest laughter to lighten the mood

during awkward exposures, or to help the patient’s anxiety to habituate, is
often appropriate and can even be beneficial. Nevertheless, it is not advised
if the patient appears highly distressed. In such instances, the therapist
should convey understanding of how difficult exposure can be, and that
with time and persistence, the exercises will ultimately become more man-
ageable. The therapist must be a keen judge of when the use of humor is be-
fitting. A good rule of thumb is to follow the patient’s lead and ensure that
308 CHAPTER 12
he or she understands the therapist is laughing with, and not at him or her.
Remarks should remain relevant to the exposure situation and should not
serve to distract the patient from the task. Susan, for example, began chuck-
ling during one exposure session in which she and the therapist were eating
M&Ms off of paper towels that had touched various surfaces in public bath-
rooms: “It’s like we’re eating at a buffet of contamination,” Susan said. The
therapist then quipped, “Yes, and please don’t miss out on the toilet-fla-
vored M&Ms over here … they’re the catch of the day … mmmm!”
13
Wrapping Up and Following Up
The first part of this chapter addresses the sensitive issue of terminating
therapy for OCD. The therapist should begin to prepare the patient for the
end of treatment before the final therapy session. This involves a review of
the patient’s progress as well as deciding on whether additional follow-up
sessions will be scheduled. The second part describes a brief follow-up pro-
gram for patients who complete the active phase of therapy, yet remain at
risk for significant relapse. This program consists of several interventions,
including the didactic presentation of information about anxiety, a discus-
sion about the issue of lapse versus relapse, additional cognitive interven-
tions, planning for self-controlled ERP, and arranging for the continued
involvement of a support person.
ENDING TREATMENT
As a result of the collaboration and intense emotional experiences that ac-

company CBT for OCD, it is common for strong therapeutic (working) rela-
tionships to develop between the therapist and patient. Thus, it should not
be surprising that the end of therapy frequently evokes apprehensiveness
on the part of the patient. Thinking of continuing without the therapist’s
consistent support might be somewhat like considering the prospect of re-
moving the training wheels from a bicycle. The patient may wonder how he
or she will persist in the fight against OCD. During the closing treatment
309
310 CHAPTER 13
sessions, time should be taken to discuss this and other issues related to the
conclusion of therapy. These topics include:
• Ending response prevention.

• Assessing the patient’s outcome.
• Reviewing how helpful the patient has found the various procedures
used in therapy.
• Deciding on the need for follow-up sessions or a referral for ongoing
care.
• Considering the patient’s posttreatment social and occupational plans.
• Obtaining information about anticipated stressors and developing
strategies for managing them.
Ending Response Prevention
As formal treatment draws to a close, the return to ordinary behavior

should be discussed with patients who have been practicing complete re-
sponse prevention. When is it appropriate to perform behaviors such as
washing, cleaning, arranging, or praying? When should such behavior be
considered as residual OCD symptoms? Although the level of oversight re-
garding rituals can be eased, patients must remain aware of the antecedents
of their behaviors. As a general rule, if such behaviors are performed out of
fear, or seem uncontrolled, they are likely rituals and should be curtailed.
Thus, patients often must decide whether urges to check, wash, and so on,
are based on necessity or fear. The patient is often able to determine this on
his or her own, yet Kozak and Foa (1997) suggested developing specific
guidelines for “normal” behavior. To illustrate, for a patient who prior to
treatment checked that the door was locked by jiggling the door handle
while counting to 20, these might be suitable guidelines:
• Once the door is closed, you are allowed to turn the handle once to
make sure it is firmly locked. If the door does not open, you are to
walk away from the door.
• Returning in the middle of the day to check that the door is locked is not
allowed, even if persistent doubts and uncomfortable images arise.
For someone who took full showers multiple times each day to avoid
sickness from germs, the following might be appropriate:
• Showers may be taken only once per day—in the morning before get-
ting dressed—and should not exceed 10 minutes in length. Excep-
tions to this rule include after vigorous exercise (i.e., if there is extreme
perspiration and body odor) and before getting dressed if going out
WRAPPING UP AND FOLLOWING UP 311
for the evening. During any shower, each body part may be washed
only once.
• Even after having a particularly messy bowel movement or changing
an especially messy diaper, there is to be no extra showering.
Sometimes, the new rules will not conform to “typical” or “normal”

standards. For, example, someone who formerly engaged in religious ritu-
als, such as excessive prayer to prevent bad luck, might be asked to con-
sider greatly limiting his praying, as in the following guideline:
• You are permitted to pray once each day: before going to bed. The
only exception is if you attend a religious service. You are only to pray
about general things, such as the “family’s” health or the “children’s”
good fortune. Prayers about specific people or events constitute com-
pulsive rituals. Do not repeat any prayers.
Of course, the terms of such guidelines will rely on what is clinically nec-
essary and what the patient agrees to do. Thus, it is important to include the
patient in developing such rules. The use of Socratic dialogue to help the
patient establish such guidelines based on his or her own experiences in
therapy is likely to enhance adherence because individuals are more likely
to follow rules they have helped to arrange, rather than those that have
been imposed on them.
Assessing Outcome and Benefit

From Specific Treatment Procedures
Although progress should be informally assessed on a continual basis

throughout treatment, a more rigorous evaluation of treatment outcome—
using objective and subjective methods—should occur during the final
therapy sessions. We typically send a packet of self-report questionnaires
home with the patient during the penultimate session to be completed and
brought in for review during the last appointment. This packet contains the
Obsessive Compulsive Inventory–Revised, Beck Depression Inventory,
Beck Anxiety Inventory, Sheehan Disability Scale, Obsessive Beliefs Ques-
tionnaire, and the Interpretation of Intrusions Inventory. The subjective
component of the posttreatment assessment might include a discussion fa-
cilitated by questions such as the following:
• What have you noticed about your obsessional fears and avoidance
strategies?
• Tell me about your urges to ritualize and how you feel you can man-
age them now.
312 CHAPTER 13
• Which of the things we did in therapy did you find most helpful in
managing your obsessions and compulsive urges?
• What symptoms or other problems are you still concerned about?
After discussing these issues, the Y–BOCS severity scale, Brown Assess-
ment of Beliefs Scale, and Hamilton Depression Scale should be administered
to quantify the patient’s degree of improvement from baseline and current
symptom severity. Although it is perfectly fine for the therapist to assess his or
her own patient, rater bias can be reduced by having someone else who is fa-
miliar with the assessment measures, yet uninvolved in the patient’s treat-
ment, administer these measures. Finally, it is important to give the patient
feedback regarding his or her degree of change on the various symptom mea-
sures. Susan T.’s therapist discussed Susan’s progress in the following way:
Therapist: So, let’s look at the results of your posttreatment assessment.

On the Y–BOCS, your score is now 11. When you came for
your initial consultation, it was 27. So, this is about a 60% im-
provement in OCD symptoms. That’s right on par with what
we’d expect from CBT. Your score on the Hamilton Depres-
sion Scale went from 10 at your initial assessment to 3, which
is also what we’d expect. So, this is telling us that, at least ac-
cording to the numbers, therapy has been very helpful. How
does that fit with your own experience?
Susan: I feel so much better now. There are so many things I can do
more easily, like use the bathroom, give Jennifer a bath, leave
the house, and grade papers for work. I don’t worry nearly as
much as I used to about those things. You’ve really helped
me.
Therapist: That’s great. But, really, you’re the one who did all the hard
work. I was just your coach.
Some patients raise the issue of their residual symptoms, and whether
the remaining obsessions and ritualistic urges will ever completely disap-
pear. In discussing this issue, it is important to emphasize that “normal” ob-
sessions and rituals are a part of everyday life for just about everyone. So,
these experiences will never completely be absent. However, treatment has
changed the way the patient responds to obsessional stimuli. Therefore,
even if (or more aptly, when) obsessional thoughts and stimuli appear, the
patient will be able to manage them in healthy ways that do not lead to
problems with anxiety, fear, or wasteful avoidance and rituals. Further, the
more one practices self-controlled exposure and implements cognitive in-
terventions, the less these situations will arise. An excellent analogy to il-
lustrate this point is the following:
Therapist: Let’s suppose you decide to change your name from Susan to
Tammy. You tell everyone you know about this change and
all agree to call you Tammy from now on. At first, if someone
slips up and calls you Susan, you might still respond to them
because you had the name Susan for many years. But, as the
months and years go by, if you heard someone say Susan, you
would probably respond less and less. Nevertheless, you
would still remember that Susan used to be your name. Even
10 or 20 years later, when you heard someone say Susan, you
might still think about how that used to be your name, but
you probably wouldn’t pay much attention because you have
become well practiced at using the name Tammy. Your recov-
ery from OCD will be much the same way. You will still have
intrusive thoughts and encounter obsessional situations
from time to time. After all, everyone does. However, as you
practice your new responses to these situations—the ones
you learned in therapy—those thoughts and situations will
become less and less significant in your life and you will pay
less and less attention to them.
Discussing the Continuation of Care: Where to From Here?
If the issue has not yet been raised, a discussion of the patient’s plans for af-
ter treatment is in order. The patient should be encouraged to keep in mind
the lessons learned in therapy and understand that the therapist is avail-
able for follow-up if needed. In addition, it is important to stress the contin-
ued review of educational materials and the continued practicing of the
ERP and cognitive interventions. The patient might feel the need for addi-
tional formal or informal treatment. If so, what are the remaining problems
that need to be addressed? Is a referral to another provider in order? As a
general rule, patients who have made little progress after 16 to 20 sessions
of CBT for OCD are unlikely to benefit further by adding additional ses-
sions. Such individuals might be referred for supportive psychotherapy to
help manage existing OCD symptoms and the stress associated with them.
Attending a support group run by a local affiliate of the Obsessive Compul-
sive Foundation (www.ocfoundation.org), if available, is an excellent sug-
gestion. If residual OCD symptoms are minimal, yet there is concern about
possible relapse, a formal follow-up program, such as that described later
314 CHAPTER 13
in this chapter, can be offered. Alternatively, a less formal strategy can be as-
sumed that would involve telephone calls and less frequent (perhaps
monthly) appointments.
Considering Future Plans
It may be important to address the patient’s social and occupational plans

for after treatment. If he or she has stopped working, is there a game plan
for restarting? Are there potential stressors and other barriers to assuming a
“normal” life, such as family turmoil, lack of social support, or residual dis-
ability from OCD? In some cases, successful treatment leaves formerly de-
bilitated patients with exorbitant amounts of “downtime” that used to be
taken up with compulsive rituals. The final sessions should involve discus-
sions of how such time can be managed, including the possible referral to
social service agencies or an occupational therapist. Volunteer work is often
an excellent suggestion for easing the patient into a workday schedule. The
volunteer work, which should be carefully chosen so that it is a rewarding
activity for the patient, can be increased gradually as necessary until the
goal of a full day is reached.
Preparing for Stressors
Patients should be informed that even in the best case scenario, they can ex-
pect to experience bumps in the road with residual OCD symptoms. Most
often, these will occur during times of increased life stress, such as in the
midst of occupational or family conflict, following a death or serious illness
in the family, job changes, and around the time of childbirth. Thus, patients
can be assisted with identifying “high risk” periods during which they
should be ready to apply the techniques learned in therapy, if obsessions or
safety behaviors become more numerous or distressing. Therapists should
also refer to the section on lapse versus relapse.
MAINTAINING TREATMENT GAINS
Although most patients have some residual OCD symptoms at the end of
treatment, they now have the tools to manage such problems and keep
them under control. This section describes the topics to be included in a
brief follow-up program for OCD patients who have completed an ade-
quate trial of exposure-based CBT. The curriculum presented here is
based on programs described previously by Öst (1989), Hiss, Foa, and
Kozak (1994), and McKay (1997). In general, the program emphasizes

practicing the skills learned during the active therapy period; namely
exposure, response prevention, and cognitive techniques. Follow-up
sessions can be initiated directly on completion of the standard CBT
protocol described in the previous chapters (i.e., as a maintenance pro-
gram). Alternatively, these procedures can be incorporated into
booster sessions for patients who, after completing a course of CBT, be-
gin to experience a return of symptoms at some later point. In either in-
stance, follow-up sessions should occur no more frequently than once
per week to allow ample time for the patient to practice by himself or
herself. In our clinic, no more than six weekly follow-up sessions are
scheduled at one time. The follow-up program should incorporate the
following components:
• Identifying high-risk situations and the relationship between OCD

and stress.
• Practicing a lifestyle of confronting, rather than avoiding, obsessional
stimuli.
• Preventing lapses from becoming relapses.
• Practicing evidence-based thinking.
• Maintaining social support.
High-Risk Situations
Even following successful treatment, most patients report that certain

situations or thoughts occasionally still evoke ritualistic urges. These
stimuli can be viewed as high-risk situations. It is important for pa-
tients to be aware of these stimuli and plan ahead if confrontation
with them is anticipated. This allows the patient to plan in advance
the kinds of appropriate coping strategies (i.e., cognitive techniques)
that can be put to use. If the patient can anticipate high-risk situations,
he or she will be better prepared for them. Times of increased life
stress might themselves be high-risk situations. It is important to re-
view with patients that OCD symptoms wax and wane, often related
to the degree of stress in a person’s life. When stress is high, patients
need to prepare themselves for the possibility of increased obsessions
and ritualistic urges. Self-monitoring (as was done during regular
treatment) is a useful tool to help patients identify changes in the fre-
quency of their symptoms.
Often, high-risk situations involve stimuli or the use of safety behav-
iors that were not identified or adequately addressed during therapy, and
316 CHAPTER 13
therefore continue to be associated with dysfunctional beliefs. If this is the

case, it should be pointed out that unless such situations are now properly
addressed, the patient can expect continued difficulty. For example, one
patient treated in our clinic worked as a funeral director. Although this
man successfully confronted many obsessional situations and stimuli,
and refrained from most of his washing rituals during treatment, he chose
to continue wearing extra gloves to protect himself against “dead body
germs” he thought would cause him and his family to become seriously
ill. Unfortunately, a few months after the conclusion of treatment (which
was generally successful), some “contaminated” materials came into con-
tact with his shoes, which ignited avoidance and cleaning rituals that
snowballed until he was again showering in the middle of the day and
asking his children to wash and clean themselves excessively. High-risk
situations, such as this patient’s contaminated shoes, become the expo-
sure targets during the follow-up phase.
Practically speaking, once a set of high-risk situations is identified, a
brief exposure hierarchy is developed. Because the patient is already accus-
tomed to the treatment procedures, there is no need to begin with less anxi-
ety-evoking stimuli. However, before beginning, it is important to ensure
that the patient has retained a complete understanding of the rationale for
exposure. Because only a handful of follow-up sessions are typically sched-
uled, situations and stimuli that cause the most distress or interference in
functioning should be confronted immediately. The patient is also assigned
daily programmed exposure practice for homework. The following anal-
ogy of someone learning to play the piano can be used to convey the impor-
tance of continued programmed and lifestyle exposure practice even after
formal therapy has ended.
Therapist: Let’s say you wanted to learn to play the piano. So, you de-
cide to take lessons for 6 months. After completing 6 months
of lessons, you would still only know the basics of how to
play the piano, and by no means would you be an expert mu-
sician. To become a skilled pianist, you must continue to
practice, learn more and more songs to understand different
styles of playing, improve your coordination, and progres-
sively refine your playing ability. If you were to stop playing,
even after finishing the lessons, your skill level would gradu-
ally deteriorate until you would be back to square one. Then
if you tried to play, you would find that you didn’t know how
to any more. The same is true for the skills you learned during
treatment of OCD. If you continue to practice confronting
rather than avoiding situations that make you distressed, and
if you continue to practice resisting urges to ritualize, you
will continue to improve your use of these skills, and you

would be able to use them no matter what challenging situa-
tions came your way. On the other hand, if you return to your
old habits of avoidance and rituals, you will find that OCD
symptoms gradually return. It’s a case of “use it or lose it.”
Maintaining a Lifestyle of Exposure
By the end of treatment, patients have learned a variety of behavioral

and cognitive techniques for keeping OCD symptoms in check. As I dis-
cussed in chapter 12, patients must incorporate lifestyle exposure as a
daily habit, in addition to practicing programmed exposure exercises.
One important topic to be discussed during follow-up is how to remain
motivated to persist with exposure efforts. It is useful to think of motiva-
tion in terms of rewards. In other words, what reward does exposure
bring for the patient? What does he or she stand to gain from deciding to
face, rather than avoid, his or her fears? Avoidance and rituals have re-
ward value as well: They bring about an immediate reduction in obses-
sional distress. However, in the long run, these safety behaviors
preserve dysfunctional cognitions and contribute to the persistence of
OCD. Although exposure reduces obsessional problems in the long
term, it results in short-term anxiety. The hurdle here is that humans are
more sensitive to short-term than long-term effects. Thus, safety seeking
seems (on the surface) like the best decision.
Increasing Motivation
To increase patients’ motivation for long-term maintenance, the therapist

can help the patient arrange contingencies so that exposure and abstinence
from safety behaviors have short-term reward value, and engaging in
avoidance and rituals has negative consequences. Some specific sugges-
tions are described here:
• Patients can make contracts with themselves such that enjoyable ac-
tivities (e.g., television shows, gifts, special meals, trips) can only be
done if no safety behaviors are performed for a specific amount of
time. Of course, goals should be set collaboratively, and they should
be realistic. The idea is for the patient to reinforce himself or herself
frequently and not fail very often.
• Patients can make their self-monitoring forms available for public
viewing, for example, on the refrigerator door at home. Family mem-
bers will see this and congratulate (reward) the patient on his or her
318 CHAPTER 13
progress. Posting of such forms can also serve as a reminder to the pa-
tient to keep up his or her hard work. In addition, because violations
of the response prevention rules would become public, this might
help the patient think twice about engaging in safety behaviors.
Neither of these techniques is completely painless, but this is part of the

reason they work. If avoidance and safety behaviors interfere with im-
provement, it is better to feel the “pain” now and do something about it
than to wait until it is too late. Such strategies also require patients to be
honest with themselves about their behavior. If they cheat to attain rewards
for ritual abstinence, they are only fooling themselves in the long run. Other
techniques for increasing motivation include the following:
• Making a list of the benefits of reducing OCD symptoms and the ben-
efits of working hard to prevent them from returning. For example,
how will it affect academic or job performance, social or dating activi-
ties, self-perception?
• Listing things that the patient does differently now than at the start of
the treatment program. This encourages him or her to reflect on per-
sonal progress.
• Selecting a specific short-term goal to work on, and identifying a
short-term reward for accomplishing this goal. As mentioned earlier,
the goal should be reasonable and likely to be obtained. The reward
should fit the accomplishment—perhaps something fun that the pa-
tient will do or purchase if and only if the goal is reached.
The Abstinence Violation Effect. We sometimes observe individuals

with OCD who run into trouble because they attempt to change their be-
havior by setting very rigid or absolute goals; for example, by stating
that they will never ritualize again. Inevitably, when a ritual is per-
formed, the person then berates himself or herself for violating a self-im-
posed, yet unrealistically obtainable, standard. At that point, the person
decides that because he or she has already spoiled the plan for complete
abstinence, he or she might as well continue to ritualize. This process is
called the abstinence violation effect and it is a common phenomenon
among those attempting to stop any habit such as smoking, substance
abuse, and overeating. To avoid falling prey to the abstinence violation
effect, patients must avoid “black-and-white” or “all-or-none” styles of
thinking. One way to counter this type of rigid thinking is to allow for
compromises. Patients can be helped to view their life as a continuum
wherein most of the time they will be able to manage obsessional anxiety
and resist ritualistic urges. However, on occasion, they (as would any-
one) will have their difficulties. Luckily, if rituals are performed,
patients can recover quite easily. The steps for doing so include analyz-
ing the situation (i.e., self-monitoring) and re-exposing themselves to
the situation or stimulus that evoked the ritual.
Lapse Versus Relapse
As the preceding discussion implies, patients should not be concerned with

periodic slips—such lapses are inevitable. A lapse can be considered a tem-
porary setback that is identified and dealt with effectively. However, con-
cern is warranted if lapses progress toward relapse. Relapse is defined as a
return to baseline of obsessional fear, avoidance, and safety behavior. It in-
volves thinking that all the work during therapy was for naught. The dis-
tinction between lapse and relapse is an important one for patients. If they
can identify a lapse, self-monitor, and implement ERP, they are halfway to
overcoming the lapse and avoiding relapse.
The therapist and patient should work collaboratively to develop a list of
specific strategies for managing lapses. Such strategies should draw on
what has been learned during treatment. Socratic questioning can be used
to help the patient arrive at his or her own solutions. Some useful strategies
include the following:
• Consider the difference between lapse and relapse. Expect lapses

from time to time (“not a matter of if, but when”).
• Take action to prevent the lapse from becoming a relapse.
• Determine the stimulus that evoked the fear or safety behaviors, as
well as the relevant cognitive distortions.
• Repeatedly confront the situation that evoked the lapse and refrain
from safety behaviors.
• Remain exposed to the situation until anxiety subsides naturally.
• Ask for help from a support person or call the therapist.
Logical Thinking
Although CT interventions play an important role in the treatment of OCD,

not all patients require instruction in formal cognitive restructuring tech-
niques such as those described by Beck (1976) or Burns (1980). However,
follow-up sessions present an opportunity to introduce patients to the use
of such strategies for modifying beliefs and assumptions that continue to
produce obsessional anxiety as well as other negative emotional conse-
quences. As the review of such strategies is outside the scope of this book,
the reader is referred to excellent sources of information on cognitive ther-
apy, including Beck’s (1976) text and Burns’s (1980) self-help book.
320 CHAPTER 13
Continued Social Support

Two types of social support might be important for helping patients main-
tain their treatment gains: informational support and practical support.
Informational Support. Informational support is the provision of infor-

mation required to solve a problem. For example, if you are trying to be on
time for an appointment but cannot find the street address, you stop and
ask someone for directions. This exchange of information (or informational
support) occurs informally each day in the form of childrearing or house-
hold hints, for example. Individuals with OCD require informational sup-
port from experts on OCD and its treatment, such as their therapist. This is
why it is important that patients raise questions or concerns they have dur-
ing treatment. However, once therapy has ended, patients need to find ad-
ditional sources of accurate informational support. The therapist should
play a role in identifying such resources. Although indiscriminant use of
the World Wide Web can present patients with plentiful misinformation
about OCD, certain sites do furnish a wealth of helpful information on
OCD. An annotated list of suggested Web sites is presented in Table 13.1
Practical Support. Practical support involves help and encouragement

from understanding and sympathetic family members or friends. On an
emotional level, this kind of support helps to enhance patients’ feeling of
self-worth and belonging because they feel cared for and understood. On a
practical level, such support helps the patient manage difficult situations
(i.e., lapses) by being reminded and assisted with implementing skills
learned during therapy. Whereas some patients have ready access to practi-
cal support, others are not so lucky. For those who require help with asking
for support, the following parameters should be discussed:
• What could the patient’s friends and family members do to support

efforts in fighting OCD?
• How should the patient ask others for their support?
• Who are good people to ask and who are not the best people to ask for
support?
• Who would be the easiest (and who the most difficult) to ask?
Requests for support should be assertive and specific. It is also impor-

tant for the patient to let others know he or she appreciates their interest and
support, and how their support was helpful. This recognition increases the
chances of receiving additional support. Role playing such interactions
during the therapy session might help hesitant patients to gain confidence
in asking for help.
TABLE 13.1
Annotated List of Helpful World Wide Web Sites on OCD and Anxiety Disorders
Resource and Internet Address Summary

Obsessive Compulsive Foundation (OCF)
www.ocfoundation.org The Web site for the OCF offers information about OCD and related
problems, including an “Ask the Experts” page. The Foundation is an
excellent resource for OCD sufferers and their families, and it sponsors
an annual conference.
Anxiety Disorders Association of America (ADAA)
www.adaa.org The site for the ADAA includes information about OCD as well as
other anxiety disorders. There is a “How to Get Help” link that can
help individuals find treatment providers that specialize in anxiety
disorders. The ADAA’s annual conference also offers resources for
patients and their families.
The OCD Source
www.ocdsource.com The OCD Source Web site is run by individuals with OCD and contains
a multitude of helpful resources, such as chat and message boards.
National Institute of Mental Health (NIMH)
www.nimh.nih.gov/HealthInformation/ocdmenu.cfm The NIMH OCD site includes authoritative information about OCD
including printable booklets and links to other Web sites pertaining to
research on OCD.
321
14
Addressing Obstacles
in Treatment
In many instances the course of treatment for OCD proceeds smoothly

and without complications. However, rough waters are occasionally
encountered. The therapist might have difficulty conceptualizing a
particularly complicated symptom presentation; the patient might fail
to adhere to treatment instructions; or improvement might be slow de-
spite apparent compliance with all of the therapy procedures. This fi-
nal chapter addresses common barriers to successful treatment that I
have not covered in earlier chapters. By and large, such complications
arise from two general sources: (a) patient factors, and (b) factors re-
lated to treatment delivery. Obstacles associated with the patient’s be-
havior include rejection of the treatment rationale, adherence
difficulties, extreme difficulty refraining from reassurance seeking,
and the presence of undetected safety-seeking behavior. Obstacles re-
lated to the treatment program itself include contradictory information
obtained from outside sources, the inclination to challenge the obses-
sion using cognitive techniques, the misuse of cognitive techniques as
reassurance rituals, problems with the planning and implementation
of exposure, and therapist trepidation with fully implementing the
treatment techniques. Strategies for overcoming these challenges are
also presented.
322
ADDRESSING OBSTACLES IN TREATMENT 323
PATIENT-RELATED OBSTACLES
Negative Reactions to the Cognitive-Behavioral Explanation
Whereas most patients are open to conceptualizing their OCD symptoms

in terms of cognitive and behavioral processes, some maintain a strong
belief that obsessions and compulsions are caused by a chemical imbal-
ance and therefore talk therapy will not be much help. Because such be-
liefs can lead to premature discontinuation of therapy, they are best
addressed early in treatment. The therapist should openly discuss any
doubts the patient has about the cognitive-behavioral model and indicate
that this model was developed to explain the symptoms of OCD (i.e., how
thinking and behavior are related), not necessarily what causes the prob-
lem in the first place. Treatment based on this model, therefore, does not
require us to know about the causes of OCD. The therapist might also
point out to the patient that studies have shown that CBT has effects on
brain functioning (e.g., Baxter et al., 1992).
Nonadherence
The most common obstacle encountered in CBT for OCD is the patient’s
failure to follow treatment instructions as directed by the therapist. Patients
might refuse to engage in supervised or homework exposure exercises,
balk at response prevention rules, or refuse to self-monitor their rituals. Be-
cause these interventions represent the active ingredients in therapy, non-
compliance must be dealt with early in treatment. Luckily, many problems
with adherence can be circumvented if the therapist is proactive. First, it is
critical to make sure that patients grasp the cognitive-behavioral model of
OCD and understand how their own symptoms are maintained according
to the conceptualization outlined in chapter 4. Second, the rationale for CBT
must be clear—patients should understand how engaging in difficult and
frightening therapy exercises will reduce their OCD symptoms in the long
term. These two points underscore the importance of CBT’s psychoedu-
cational component. A third strategy for avoiding adherence problems is to
ensure that the patient feels involved in the selection and planning of expo-
sure exercises and response prevention rules.
If a patient is not following through with completing exposure tasks,
the therapist should first inquire as to why. Sometimes noncompliance
with homework can be addressed with problem solving (e.g., making
more time available for practicing). It is also important to make sure that
the exposure task itself is a good match to the patient’s obsessional fears
and dysfunctional beliefs. If not, the patient might perceive the exercise as
irrelevant. If high levels of anxiety prompt refusal or “shortcuts” (e.g.,
324 CHAPTER 14
subtle avoidance or safety strategies) during exposure, the therapist

should review the importance of confronting obsessional fears and the
role of avoidance in maintaining obsessions. Cognitive strategies (e.g., So-
cratic dialogue) can then be used to identify and address the patient’s cat-
astrophic predictions about danger that underlie the reluctance to fully
confront the feared stimulus. With an understanding of the purpose of the
exercise, and the expectation that anxiety will temporarily increase before
habituation occurs, it is often possible to successfully encourage patients
to invest anxiety now in a calmer future.
Sometimes, therapists are tempted to suspend or postpone the sched-
uled exposure due to the patient’s high anxiety. Refining the exposure hier-
archy and adding intermediate items (as discussed in previous chapters)
are sometimes appropriate therapeutic maneuvers; for example, if the pa-
tient threatens to discontinue treatment. However, therapists are discour-
aged from the liberal use of these tactics, even when patients appear quite
scared. Habituation will occur at some point, and postponing exposures
only reinforces avoidance patterns and unrealistic beliefs about the danger-
ousness of objectively low-risk situations. Instead, the therapist should em-
phasize the patient’s control over exposures—it is ultimately his or her
choice to perform the tasks. However, this choice has important conse-
quences: Choosing not to complete the exercise as directed is essentially the
decision to strengthen OCD symptoms. The therapist can use motivational
interviewing techniques to create and amplify, from the patient’s point of
view, the discrepancy between nonadherence and his or her broader goals
and values. When nonadherence is perceived as conflicting with important
personal goals (e.g., self-image, happiness, success), change becomes more
likely (Miller & Rollnick, 2002).
Dealing With Argumentative Patients
During interventions such as exposure and CT, patients sometimes become

contentious and look for flaws in the psychoeducational information they
are given, rather than processing this information in a helpful way. This can
be avoided by using a less didactic style and increasing the use of Socratic
dialogue so that the belief-altering information is generated by the patient
himself or herself. If discussions about mistaken beliefs take an argumenta-
tive or combative turn, the therapist should summarize the discussion and
reach a conclusion that the patient could be correct in his or her assertions,
but that rather than taking anything for granted, it is important to closely
examine the facts or test them out. For example, if a patient strongly states
that speaking once more with the rabbi would permanently quell his need
for reassurance about fears of violating Jewish dietary laws, this should be
honestly considered. However, the ensuing dialogue should include ques-
tions about past experiences. For example, has the patient ever made the
“just one more time” promise before? If so, what was the outcome? What
could be done to find out whether the reassurance seeking is really neces-
sary? What have rabbis told him in the past, and what does he expect to
hear this time? Would it be more helpful to learn how to manage with such
situations without reassurance? This highlights the importance of main-
taining a collaborative relationship.
Therapists are strongly advised to refrain from protracted debates with
patients over the potential risks involved with doing exposure exercises and
stopping rituals. Not only are such arguments fruitless; they also reinforce
the patient’s OCD habits of spending too much time worrying about risk and
uncertainty. Essentially, arguments of this type are nothing more than an act-
ing out of the patient’s mental analyzing rituals. Moreover, when patients
perceive that the therapist is frustrated, angry, or trying to coerce them into
compliance (e.g., “You can’t make me do this.”), they tend to lose motivation.
When a reluctant patient attempts to engage in rational argument about risk
and danger, the best course of action for the therapist is to step back and rec-
ognize that the decision to engage in treatment is a difficult one. Motivational
statements, such as the following, are often persuasive:
• Remember that we both agreed on a plan for the exposures that you
would practice. I hope you will hold up your end of the agreement.
• You’re right. There is risk involved, but it is not high risk. The goal of
treatment is to weaken your anxiety about situations where it is im-
possible to have a complete guarantee of safety.
• It looks like you are having a lot of difficulty with deciding to do this
exposure, but if you are going to get over OCD, you have to confront
your uncertainty and find out that the risk is low.
• I realize most people wouldn’t do what I am asking you to do. How-
ever, the therapy isn’t about what most people do. It’s about helping
you overcome OCD. Stopping these rituals is designed to help you
learn to better manage acceptable levels of risk and uncertainty.
• You are here in treatment for yourself—not for me. So, I won’t argue
or debate with you. This is entirely your choice. However, I will point
out that you stand to gain relief from your symptoms by trying these
exercises and enduring the short-term anxiety. On the other hand, you
are the one who has to live with the OCD symptoms if you choose not
to do the therapy.
Deciding to Terminate Therapy
If, despite much effort to repair such problems, the patient persists in refus-
ing to cooperate with treatment instructions, it may be suitable to suspend
326 CHAPTER 14
therapy. For some clinicians, this might mean shifting the focus of treat-
ment to some other problem (or working on identifying where the patient’s
motivation for change does lie). For others, this might mean ending therapy
altogether. If this becomes inevitable, it should be done in a sensitive (as op-
posed to a punitive) way, and the door should be left open for the patient to
return at some point in the future. My colleagues and I have found that dis-
cussing nonadherence as indicative of “bad timing” often works well, as in
the following monologue:
Therapist: It seems to me that for whatever reasons, we are not getting

very far with therapy. I know that this treatment can be very
difficult, and you are clearly having a hard time doing the ex-
ercises that will help you overcome OCD. And so treatment
cannot be as effective for you as it should be. When this hap-
pens it means that now is not the right time for you to be in
this kind of therapy. So it is best that we stop at this point.
Maybe at some point in the future it will be a better time for
you, and you will be able to do the exercises you need to do to
benefit. I would be happy to work with you at that point.
Excessive Reassurance Seeking
Some OCD sufferers approach therapy believing the goal is to obtain the
“ultimate guarantee” of safety, which they can then apply whenever and
wherever they feel anxious. Such patients may try to hijack cognitive in-
terventions by using them to hear from an “expert” (i.e., the therapist)
that, for example, one cannot get sick from using a public bathroom or that
one will never act on unacceptable violent, aggressive, or sexual im-
pulses. Whereas efforts to gain assurances are usually straightforward
and easily identified (most patients will ask the same questions again and
again—perhaps in different ways), some patients are more subtle. Keen
judgment is sometimes needed to assess whether the function of ques-
tioning truly is reassurance seeking. Once patients understand the prob-
lems associated with reassurance seeking, it is appropriate to ask about
the purpose of suspected questions (e.g., “You’ve asked me that question
a few times today; are you trying to get me to reassure you about this?”).
In my own work, when I hear myself repeating the same information to a
patient more than once or twice, it is a signal to consider whether I am un-
intentionally helping the patient to ritualize.
The problem with providing assurances, of course, is that the patient
learns nothing about the process of evaluating his or her dysfunctional be-
liefs. Moreover, during exposure, reassurance seeking prevents prolonged
confrontation (and habituation) to the feared situation, which involves be-
ing uncertain about the feared consequences. It is therefore important for

the therapist to recognize the patient’s attempts to seek reassurance and
avoid the temptation to ease the patient’s distress by providing guarantees.
Some patients have difficulty resisting urges to seek reassurance even
when given instructions not to do so. Excessive and persistent reassurance
seeking must be handled with caution because miscommunications can de-
rail therapy. Next I describe some useful ways my colleagues and I have
addressed these problems (Abramowitz, Franklin, & Cahill, 2003).
Appeals to Authority. In some instances patients desire a consulta-

tion with an expert on the feared situation or stimuli. For example, indi-
viduals with religious obsessions often seek reassurance from clergy. One
man, who feared that he was becoming schizophrenic, persistently
e-mailed and telephoned various OCD experts to ask questions on the re-
lationship between OCD and schizophrenia. Requests for such consulta-
tions should be considered and discussed in light of whether or not they
will be helpful for moving the patient toward overcoming his or her need
for certainty. In some instances, a single consultation with an expert might
be appropriate, especially if this would prevent the patient from discon-
tinuing treatment. However, the aim of such a consultation is to establish
guidelines about safety—not to inquire about every possible situation
that could arise. Patients must learn to apply judgment about risk rather
than know for sure about the probability of harm in specific feared situa-
tions. In preparation for meeting with an expert, the patient and therapist
should agree on certain broad questions that will be addressed, and the
therapist should be present to ensure that excessive ritualizing (i.e., reas-
surance seeking) does not occur.
A similar situation arises when patients turn to the Internet or other
“authorities” (e.g., medical references) for reassurance. Such behavior of-
ten leads to obtaining incorrect or contradictory information that aug-
ments uncertainty and strengthens inaccurate beliefs. For example,
patients might read about and misinterpret statistics regarding the rela-
tionship between hand washing and illness. Individuals with the habit of
searching Web sites for information about each situation in which obses-
sional fear is evoked should be persuaded to cease and desist from such
behavior during treatment (i.e., as part of response prevention) because
the aim of therapy is to learn to rely on judgments about risk that are de-
rived from real-world evidence.
Asking for Reassurance During Exposure. When patients desire a

guarantee of safety during exposure exercises (e.g., “Are you sure I’m not
going to get sick if I touch the toilet seat?”), the first inclination may be to
put them at ease by reassuring them they are not in any danger. However,
328 CHAPTER 14
this undermines the goal of living with acceptable levels of risk and uncer-
tainty (indeed, people routinely touch toilet seats). On the other hand, the
patient should not be made to feel as if he or she is at high risk for negative
consequences. Thus, the ideal response uses empathy, focusing on how ex-
posures are designed to evoke uncertainty and how there can never be an
absolute guarantee of safety. A general rule to keep in mind is that ques-
tions about risk in a given situation should be answered only once. Addi-
tional queries should be pointed out for the patient and addressed in the
following way:
Therapist: I can tell you’re feeling uncomfortable and are searching for a
guarantee right now—that’s your obsessional doubting. Be-
cause I already answered that question, it would not be help-
ful for you if I answered it again. The best way to stop the
obsessional doubts is for you to practice tolerating the dis-
tress and uncertainty. How can I help you to do that?
The therapist must also be alert for more subtle attempts to seek reassur-
ance. As an example, one patient would make strategic statements (e.g.,
“Now that we’ve touched the toilet, I’m going to go home and play with my
6-month-old”) and then scrutinize the therapist’s facial expression for signs
of concern. If such assurance seeking is suspected, this should be confirmed
and discussed with the patient. The rationale for not seeking such assur-
ances should also be revisited.
My colleagues and I have worked with some individuals who were com-
pletely unable (or unwilling) to resist persistent urges to seek reassurance
both within and between therapy sessions. The uncertainty evoked by their
OCD symptoms, which was intensified by doing exposures, was too much
for them to bear. Because the persistence of assurance-seeking rituals inevi-
tably compromises treatment outcome, therapy had to be suspended in
these cases. As addressed earlier, suspension is the last resort when patients
refuse to comply with treatment procedures and it is imperative that the
therapist convey in a caring and sensitive way that discontinuation is rec-
ommended when patients are unable to carry out the treatment procedures
in ways that would be beneficial.
Presence of Subtle Safety-Seeking Behaviors

Sometimes, patients fail to show a reduction in fear even after repeated
trials of well-executed prolonged situational or imaginal exposure. If this
occurs, it may be the result of subtle, undetected safety maneuvers (e.g.,
undetected mental rituals) that the patient continues to use to avoid
feared consequences. Although some individuals blatantly use safety be-
haviors to avoid distress during exposure, others might use them quite in-
nocently and are not aware that they are doing anything to disrupt
treatment. Nevertheless, use of any safety behaviors during exposure
snarls the process of habituation and cognitive change as I have de-
scribed. In such cases, the therapist should inquire carefully about any
sorts of strategies (behavioral or mental) the patient is using to reduce
anxiety or prevent harm during exposure. Any identified safety maneu-
vers must, of course, be dropped in subsequent exposures.
OBSTACLES RELATED TO TREATMENT DELIVERY
Contradictory Information From Other Sources
Unfortunately, patients are often exposed to information that conflicts

with what is taught in CBT for OCD. Misleading data may be gleaned
from sources such as another treatment provider or paraprofessional
(e.g., a pastoral counselor), radio and television advertisements for phar-
maceutical products, and educational materials (print or Internet-based)
about OCD. For example, one popular mental health Web site suggests in-
correctly that thought stopping and aversive conditioning are effective in-
terventions for OCD:
Through thought-stopping, the individual learns how to halt obsessive

thoughts through proper identification of the obsessional thoughts, and then
averting it by doing an opposite, incompatible response. A common incom-
patible response to an obsessive thought is simply by yelling the word
“Stop!” loudly. The client can be encouraged to practice this in therapy (with
the clinician’s help and modeling, if necessary), and then encouraged to
transplant this behavior to the privacy of their home. They can also often use
other incompatible stimuli, such as tweaking a rubber-band which is around
their wrist whenever they have a thought. The latter technique would be
more effective in public, for example. (PsychCentral, 2004)
Of course, the use of thought stopping contrasts with one of the chief
principles of CBT for OCD: that intrusive obsessional thoughts are entirely
normal and therefore not something to be avoided or suppressed. In fact,
CBT helps patients confront their obsessional thoughts (precisely the oppo-
site of thought stopping) as a way of learning to view the intrusions as
harmless. It is also well known that aversive conditioning is not an effective
way to manage obsessions (the only result is a sore wrist).
If a patient is receiving CBT from one provider, and another
psychosocial intervention (e.g., religious counseling) from a different pro-
vider, it is critical that the clinicians support one another in terms of the
kind of advice they give. This may be best accomplished through periodic
communication between the treatment providers (Taylor, 2000). Receiv-
ing contradictory advice from two or more “authorities” can lead to con-
330 CHAPTER 14
fusion, or worse, cause the already anxious patient to worry further about
satisfying two providers who are giving them incompatible directives (as
in the case of exposure vs. thought stopping). In such cases, the best op-
tion is sometimes to suspend CBT until the patient has completed treat-
ment with the other provider.
Inclination to Challenge the Obsession
It is tempting for therapists to fall into the trap of challenging the logic of
obsessional thoughts per se (e.g., “the impulse to attack a child”) rather
than challenging the patient’s faulty beliefs and interpretations of the
thoughts (e.g., “The thought means I am a very dangerous person who is
unfit to be a parent”). Intuitively, the obsession itself seems like a good tar-
get for cognitive interventions because it is both a cognition and foremost
on the patient’s list of complaints. It is also usually illogical. Yet, recall that
the obsession is considered the “A” in the A-B-C model of cognitive ther-
apy. It is the normally occurring (uncontrollable) activating event about
which the patient has dysfunctional beliefs (Bs). It is the Bs that require
modification if treatment is to be successful. Because most patients al-
ready recognize their obsessions as irrational, directly challenging the va-
lidity of these thoughts will likely have only a transient therapeutic effect.
Moreover, such challenges could turn into reassurance-seeking rituals or
maladaptive neutralization strategies used in response to the particular
obsession (Salkovskis, 1985).
The best way to avoid challenging obsessions is to ensure that intrusive
thoughts are differentiated from catastrophic interpretations and apprais-
als of obsessions (i.e., automatic thoughts and dysfunctional assumptions).
Because both are cognitive events, disentangling them can be tricky. How-
ever, this can be clarified if the therapist considers the ego-dystonic intru-
sive thought not as the cognitive basis of distress itself, but rather as a
stimulus about which the person has automatic thoughts and interpreta-
tions. Chapter 8 provides specific suggestions to help the therapist assess
appraisals and interpretations of obsessions across the various OCD symp-
tom dimensions. Table 9.2 also illustrates differences between obsessional
stimuli and automatic thoughts about these stimuli.
When Cognitive Challenges Become Rituals

As mentioned previously, it is possible for psychoeducational material and
information learned through Socratic dialogue to be converted into reas-
surance-seeking rituals or neutralization strategies. For example, after
learning about the CBT model, one patient ritualistically repeated the
phrase “obsessional thoughts are normal” to reduce anxiety associated
with her intrusive thoughts of harming her baby. Moreover, this phrase had
to be repeated three times “perfectly” before she could stop the ritual. Other
patients become preoccupied with finding the single “best” way of chal-
lenging their obsession or identifying the phrase that “most completely” re-
assures them that feared consequences are impossible. The therapist can
reduce the chances that CT techniques will become rituals by avoiding the
provision of guarantees during CT. For example, rather than telling patents
that they “probably won’t get sick,” it is better to explicitly say that the
probability of becoming sick, although acceptably low, is not zero.
Freeston and Ladouceur (1999) suggested that if the patient repeats the
same cognitive analysis, uses it in a stereotypic way, or requires increasing
efforts to reduce distress, it means such material is being used for the pur-
poses of neutralizing. In contrast, healthy use of CT techniques allows the
patient to generate new interpretations of obsessional stimuli that lead to
acting appropriately during exposure (managing distress, taking “risks”).
For example, Susan T. was taught how to use her cognitive challenges to
think less catastrophically about her intrusive thoughts, and then to engage
in an exercise (e.g., holding or bathing the baby) to demonstrate that her
feared consequences were unlikely.
Unbearable Anxiety Levels During Exposure

If the patient has difficulty tolerating an exposure—if he or she becomes ex-
tremely anxious and emotionally reactive, or fails to habituate—it probably
means the task chosen for that particular session is too difficult. In such cases,
the exercise should be stopped and the therapist should assess the cognitions
underlying the intense anxiety. If the patient becomes concerned that treat-
ment is not working because anxiety did not subside, the therapist should
emphasize that therapy is a process that requires continued practice. More-
over, it can be pointed out that the patient took an important step simply by
choosing to enter the feared situation at all (something he or she had been
avoiding). If the patient refuses to tolerate high levels of anxiety, even after an
appropriate intermediate exposure task has been identified, an alternative
consideration is that depressive symptoms are interfering with habituation
(e.g., Foa, 1979; Foa et al., 1983). In such cases, strategies to help manage de-
pression might be undertaken before attempting exposure for OCD.
Absence of Anxiety During Exposure
At the other extreme, a patient might report that the planned exposure task
evokes little or no discomfort. On the one hand, this could be an encourag-
ing sign—the once-feared situation may no longer evoke distress because
the patient’s expectations about danger have been modified in some other
way. This is most likely to be the case toward the end of treatment, once the
patient has gained confidence with conducting exposures. If early expo-
332 CHAPTER 14
sures evoke little or no anxiety, it is wise to troubleshoot rather than assume

that the patient has improved very rapidly. Absence of anxiety during ex-
posure could result if the key anxiety-evoking aspects of the feared situa-
tion have not been incorporated into the exposure. This can be assessed and
resolved by directly asking the patient why the exposure did not evoke anx-
iety, or how the situation could be made more anxiety evoking. The plan-
ning of subsequent exposures must then take this information into account.
A second possibility is that the patient has in some way nullified the ex-
posure with cognitive avoidance or safety-seeking behavior. For example,
before undertaking exposure to contaminating her son with “floor germs,”
one very religious patient ritualistically reminded herself that her son’s
health was entirely in God’s hands. This maneuver functioned to absolve
her of the responsibility for harm and therefore she did not become anxious
even when feeding her son candy that had touched the floor. If avoidance
and safety-seeking behavior is suspected, the therapist should carefully as-
sess for its presence (e.g., “Is there anything you are doing, or anything you
are telling yourself, that might make the exposure less distressing?”). The
use of such strategies may indicate a problem understanding or accepting
the rationale for exposure. If the patient does not see how exposure will be
helpful, there will be little motivation to purposely subject himself or her-
self to additional anxiety. Additional time spent with psychoeducation
might be necessary. Alternatively, the selected exposure task may simply be
too frightening and a less distressing one should be considered.
When Exposure Exercises Go Amiss

Although the therapist aims to arrange exposure tasks that involve mini-
mal risk, minimal risk is not the same as no risk. It is therefore possible for
exposure to result in negative outcomes. Some examples from my, and my
colleagues’, experience include the following:
• A woman who was afraid of making mistakes while paying bills (she
thought this would result in her utilities being turned off) conducted
an exposure in which she wrote bank checks and completed her state-
ments rapidly and without double-checking to ensure accuracy.
However, she made an actual mathematical error during one assign-
ment and sent the incorrect amount (too little) to the electric company.
• A patient with fears of contamination from fruit ate a fairly large
quantity of berries and melon for an exposure. That evening he en-
countered problems with diarrhea that he believed resulted from con-
taminated fruit.
• A man conducting exposure to driving while speaking on his cell
phone—he had obsessions about hitting pedestrians without realiz-
ing it—accidentally made a wrong turn onto a one-way street. Fortu-

nately, there were no oncoming cars.
• A woman with obsessional fears of contamination from public bath-
rooms, and her therapist, both came down with colds the day after ex-
posure to touching door handles from public bathrooms.
Initially, such occurrences might seem like setbacks. Exposure is sup-

posed to disconfirm such fears. However, this is not necessarily the case.
Recall that patients overestimate both the probability and severity of nega-
tive outcomes. Thus, if an exposure exercise goes wrong, the therapist can
salvage some benefit from the experience by helping the patient modify
cognitions about the “awfulness” of the “dreaded” outcome, acknowl-
edging that sometimes negative events do happen. That is, the therapist
can point out that although something negative occurred as a result of ex-
posure, (a) the result was probably not as bad as the patient would have
anticipated, and (b) the patient was able to deal appropriately with the sit-
uation. Such experiences probably build the patient’s self-efficacy be-
cause they draw attention to his or her underestimated ability to cope
with adversity. Next, I explain how each of the problematic exposures just
described were resolved:
• The woman who underpaid her electric bill received a notice from the
electric company informing her of the error and asking that she please
pay the balance of last month’s bill along with next month’s bill. She
learned that even if she made a mistake, she would have other
chances before her utilities were shut off.
• The patient who experienced diarrhea after eating fruit told his wife
that he believed the fruit he ate during exposure was contaminated
and that now he was ill. His wife, who happened to be a dietitian, per-
ceptively pointed out that the diarrhea was probably a normal gastro-
intestinal response to the sudden change in diet (increase in fiber).
The patient had been avoiding eating fruit for a long time.
• The man who turned the wrong way down a one-way street quickly
corrected his mistake and, although distressed at making the wrong
turn, learned that he was able to recognize such errors. He concluded
that if he was able to notice such a mistake so quickly, he would proba-
bly also realize if he had hit a pedestrian.
• The woman who, along with her therapist, caught a cold after the
bathroom exposure made the following comment: “I’m not happy to
have a sore throat and a cold, but if this is the worst thing that hap-
pens if you touch a bathroom door, then I shouldn’t worry about it as
much as I do.”
334 CHAPTER 14
Therapist Discomfort With Exposure Exercises

Finally, it is normal for beginner therapists, or those new to the use of expo-
sure-based therapy for anxiety, to feel trepidation in asking patients with OCD
to purposely confront stimuli that evoke obsessional anxiety and then resist
safety-seeking behaviors. Perhaps the exercises seem unnecessarily painful.
One might consider the following points if such consternation sets in.
• We know from a solid foundation of research that exposure-based

therapy is the treatment of choice for OCD, and that without it, pa-
tients have less hope of improving. Ultimately reducing pathological
anxiety, avoidance, and rituals requires temporarily evoking anxiety
and urges to perform the unwanted behaviors.
• Exposure therapy does not demand anything of the patient that he or
she is not already doing. That is, patients are already thinking their
distressing thoughts repeatedly—this is the definition of an obses-
sion. Exposure simply asks that the patient evoke the obsessional
thought in a systematic and therapeutic fashion to practice more
healthy ways of managing such situations. Further, there is no evi-
dence that it is dangerous or harmful to interrupt a person who is en-
gaged in compulsive rituals. At worst, interruption evokes
temporary discomfort (e.g., Rachman & Hodgson, 1980).
• It is clear that the patient’s habitual responses of attempting to avoid,
resist, and control obsessional stimuli are maladaptive and serve only
to maintain the associated distress and impairment. The cognitive-be-
havioral model posits that a much healthier strategy for dealing with
obsessions is to consider them as normal mental stimuli that need not
be resisted or controlled. Thus, exposure helps the patient experience
his or her feared situations and intrusive thoughts in a way that leads to
the development of more adaptive responses to these stimuli. More-
over, the new responses have the added benefit of being rational.
• The distress evoked during therapeutic exposure is temporary. When
it decreases, patients are left with important knowledge about situa-
tions and thoughts they once believed were dangerous, and about
their own ability to manage their own subjective distress.
• Amelioration of certain fears by exposure will not cause “symptom
substitution” of additional problems. There is no evidence that obses-
sional fears and rituals are caused by unconscious conflicts that per-
sist until they are resolved.
• Although exposure requires that the therapist purposely help the
patient become anxious, I have found that when the rationale for
these procedures is clear, and the treatment plan has been estab-
lished collaboratively, the intervention engenders a warm and sup-
portive working relationship that further authenticates the patient’s
courage and progress.
Appendix A:
OCD Treatment History Form
for Assessing the Adequacy
of Previous Cognitive-
Behavioral Therapy Trials
336
337
Appendix B:
The OCD Section
of the Mini International
Neuropsychiatric Interview
(MINI)
Note. Reprinted with permission from David V. Sheehan, MD, MBA.

339
Appendix C:
Yale–Brown Obsessive
Compulsive Scale Symptom
Checklist and Severity Scale
Note. Reprinted with permission from Wayne K. Goodman, MD.

341
342
343
344
Appendix D:
The Brown Assessment
of Beliefs Scale
Note. Reprinted with permission from Jane Eisen, MD.

346
347
Appendix E:
The Obsessive–Compulsive
Inventory–Revised Version
(OCI-R)
Note. Reprinted with permission from Edna B. Foa, PhD.

349
Appendix F:
The Obsessive Beliefs
Questionnaire and Interpretation
of Intrusions Inventory
351
352
353
354
355
Appendix G:
Interview on Neutralization
Note. From “Strategies Used With Intrusive Thoughts: Context, Ap-

praisal, Mood, and Efficacy,” by M. Freeston, R. Ladouceur, M. Provencher,
and F. Blais, Journal of Anxiety Disorders, 9, pp. 201–215. Copyright 1995 by
Elsevier. Reprinted with permission.
Probe questions:
When you have this thought …
• Do you reassure yourself by talking to yourself? What did you say? What
else might you say?
• Do you seek reassurance by talking to someone? Who do you talk to? Do you
talk to anyone else?
• Do you perform some type of mental or observable action to remove the
thought?
• Do you try to think it through?
• Do you replace the thought with another?
• Do you distract yourself with the things around you?
• Do you throw yourself into an activity?
• Do you say “stop” or something else?
• Do you sometimes do nothing with the thought?
• Do you do anything else that hasn’t been covered? What do you do?
Follow-up questions for each strategy identified:
• Do you use this strategy in a particular situation or context?
• How intense is the thought just before you use this strategy? (0–4)
• How probable does the thought seem just before you use this strategy? (0–4)
• Do you generally use this strategy in a particular sequence, for example
when one strategy hasn’t worked, or before trying another?
• What are the emotions you feel just before you use this strategy?
• How intense is the emotion at this point? (0–4)
• How effective is the strategy in removing the thought immediately after you
use it? (0–4)
Rating scale:
0 1 2 3 4
Not at all A little Moderately Veru Extremely
357
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Author Index
Note: f indicates figure, h indicates handout, n indicates footnote, t indicates table.
A Aublet, F., 70, 368
Abbruzzese, M., 59, 358 B

Abramowitz, J., 7, 22, 23t, 31, 32, 33, 35, 40,
41, 42f, 48, 55, 56, 59, 60, 61, 63, Baer, L., 28, 58, 60, 108, 113, 133, 149, 154,
64t, 65, 70, 73, 75, 82, 83, 94, 100, 360, 361, 363, 366, 369, 374, 377
107, 108, 109, 110, 111, 112, 114, Barlow, D. H., 77, 130, 212, 360, 362
115, 116, 145, 149, 150, 154, 175, Barr, L. C., 47, 368
249, 287, 327, 358, 359, 360, 362, Basoglu, M., 112, 114, 115, 368, 369
363, 364, 365, 370, 374, 376, 377 Baxter, L. R., 56, 58, 323, 360
Ackerman, D. L., 150, 361 Bayen, U. J., 59, 60, 61, 377
Adams, P. L., 30, 360 Beck, A. T., 61, 66, 90, 103, 135, 319, 360, 368
Akhtar, S., 8, 73, 360 Beens, H., 104, 363
Akiskal, H., 51, 367 Beer, D. A., 133, 363
Alarcon, R. D., 62, 360 Bellodi, L., 59, 358
Aldemann, U., 250, 367 Berger, M., 56, 363
Alonso, P., 72, 360 Bergman, K. S., 58, 360
Alterman, I., 55, 367 Bienvenu, O. J., 35, 36t, 370
Amaro, E., 58, 369 Black, D. W., 34, 35, 361
Amir, N., 59, 61, 70, 134, 364, 376 Blais, F., 183, 365
Amoriam, P., 130, 374 Bland, R. C., 33, 35, 368, 377
Andrew, C., 58, 369 Blier, P., 150, 374
Andrews, G., 35, 36t, 102, 134, 362, 369 Blum, N., 35, 361
Antony, M., 7, 36t, 61, 83, 211, 360, 369, Boardman, J., 7, 22, 369
372, 375 Boll, T. J., 62, 360
Arntz, A., 77, 104, 105, 208, 274, 360, 376 Bondi, C., 7, 22, 369
Asmundson, G. J. G., 48, 193, 287, 375 Borgeat, F., 115, 371
Atala, K. D., 133, 363 Bota, R. G., 56, 374
379
380 AUTHOR INDEX
Boulougouris, J., 96, 246, 372 Cumming, S. R., 88, 370

Bouton, M. E., 302, 361
Bouvard, M., 114, 115, 362 D
Bowers, T., 40, 375
Brault, M., 115, 371 Davenport, R., 34, 368
Breiter, H., 60, 361 Davies, M. I., 83, 377
Brigidi, B., 32, 48, 59, 61, 70, 358, 376 Davies, S., 102, 114, 115, 364
Brody, A. L., 56, 374 Davis, J., 20, 374
Brown, D., 121, 361 Davis, M., 40, 375
Brown, G., 135, 360 Deacon, B. J., 7, 73, 154, 358, 362
Brown, H. D., 58, 60, 361, 374 DeCaria, C. M., 55, 367
Brown, T., 30, 130, 362, 366 De Cort, K., 60, 366
Burnam, A., 33, 368 de Haan, E., 102, 104, 113, 115, 363, 376
Burns, D., 319, 361 Deilber, M., 58, 362
Bux, D. A., Jr., 115, 364 Delgado, P., 7, 100, 365
Bystritsky, A., 150, 361 Demal, U., 35, 362
de Silva, P., 4, 17, 18, 33, 63, 64t, 65, 103,
C 194, 362, 372
DeVeaugh-Geiss, J., 114, 362
Cabranes, J. A., 56, 362 de Vries, A. L. C., 47, 368
Cahill, S. P., 73, 175, 249, 327, 359 DiBernardo, C., 75, 112, 287, 359
Calamari, J. E., 22, 83, 153, 361, 367, 370 Diefenbach, G., 116, 359, 376
Calvocoressi, L., 34, 361 DiNardo, P., 130, 362
Campbell-Sills, L. A., 30, 366 Dollard, J., 38, 362
Campeas, R., 102, 114, 115, 364 Doppelt, H. G., 102, 150, 331, 364
Canino, G. J., 33, 35, 377 Downie, F., 36t, 360
Carmin, C., 33, 65, 359 Dugas, K., 63, 365
Carter, S. R., 82, 377 Dugas, M. J., 5, 19, 20, 63, 368
Cassiday, K. L., 153, 361 DuPont, R. L., 34, 362
Catapano, F., 34, 369 Dyck, I., 34, 35, 375
Chambless, D., 59, 60, 61, 113, 150, 151,
153, 361, 373, 377
E
Channabasavanna, S. M., 73, 368 Ebert, D., 56, 363
Chorpa, M., 57, 364 Ecker, W., 60, 363
Christensen, G., 40, 361 Edwards, C., 59, 361
Ciarrocchi, J. W., 250, 361 Eelen, P., 60, 366
Cinotti, L., 58, 362 Einstein, D. A., 88, 370
Clark, D. A., 69, 82, 103, 361, 372 Eisen, J., 15, 33, 34, 35, 133, 134, 363, 373,
Clark, D. M., 103, 361 375
Clavan, M., 5, 63, 370 Ellis, A., 104, 363
Clayton, I., 59, 361 Emery, G., 90, 103, 360
Cobb, J., 114, 115, 369 Emmelkamp, P. M. G., 72, 96, 104, 113,
Cohen, A. B., 73, 175, 249, 359 306, 363, 367
Cohen, D., 26, 46, 47, 114, 115, 368, 369, 371 Encinas, M., 56, 362
Coles, M. E., 15, 26, 70, 89, 134, 176, 191, Engelkamp, J., 60, 363
361, 364, 368 Enright, S., 51, 363
Constans, J., 60, 361 Epstein, N., 135, 360
Cooper, T. B., 55, 367 Erlbaugh, J., 135, 360
Cottraux, J., 58, 105, 114, 115, 362 Eysenck, H. J., 54n1, 363
Craske, M. G., 4, 212, 362
Crespo, M., 72, 360 F
Crespo-Facorro, B., 56, 362
Crino, R., 35, 36t, 102, 134, 362, 369 Fallon, B. A., 47, 363
Cullen, S., 58, 369 Fals-Stewart, W., 100, 146, 363
AUTHOR INDEX 381
Feeny, N. C., 115, 364 Greene, K. A. I., 149, 365

Fernandez Perez, C., 56, 362 Greenwald, S., 33, 35, 377
Ferri, S., 59, 358 Greist, J. H., 113, 114, 149, 154, 366, 369
First, M. B., 130, 363 Grice, D. E., 7, 22, 47, 368, 369
Fischer, S. C., 98, 364 Grisham, J. R., 30, 366
Fitzgerald, K. D., 56, 363 Gross, R. C., 29, 57, 365, 366
Fleischman, R. L., 7, 100, 133, 365 Guarneri, M., 34, 369
Florin, I., 60, 377 Gully, R., 55, 367
Foa, E., 7, 8, 22, 31, 32, 35, 48, 59, 60, 61, Guze, B. H., 56, 58, 323, 360
70, 82, 83, 94, 95, 96, 97, 98, 99,
100, 102, 107, 108, 109, 110, 112, H
113, 114, 115, 134, 135, 145, 150,
232, 251, 253n1, 257, 274, 280, Hafner, R. J., 72, 113, 366
304, 310, 314, 331, 358, 359, 361, Haidt, J., 175, 366
363, 364, 365, 366, 368, 373, 376 Hajcak, G., 135, 364
Folstein, M. F., 34, 371 Halpern, B., 110, 365
Forrester, E., 70, 79, 83, 175, 373, 374 Hamilton, M., 134, 366
Franklin, M., 7, 22, 23t, 31, 32, 60, 75, 94, Hamlin, C., 60, 83, 376
102, 107, 108, 109, 110, 112, 113, Hammond, D., 59, 61, 62, 373
114, 115, 145, 149, 150, 287, 327, Hand, I., 115, 367
359, 361, 363, 365 Hannan, S. E., 116, 376
Freeston, M., 5, 11, 19, 20, 63, 69, 70, 72, Hanusa, B. H., 33, 377
73, 107, 149, 183, 238, 331, 365, Harnett-Sheehan, K., 130, 374
368, 374, 376 Harris, L. M., 88, 370
Freidman, S., 110, 153, 366 Harris, M., 34, 361
Fritzler, B. K., 154, 365 Harrison, J., 63, 374
Froment, J., 58, 362 Hartl, T. L., 29, 149, 365, 366
Frost, R. O., 15, 26, 29, 30, 63, 68t, 70, 89, Hatch, M. L., 153, 366
149, 176, 202, 361, 365, 366, 375 Hecker, J. E., 154, 365
Furr, J. M., 7, 22, 23t, 31, 149, 359 Hedlund, J., 134, 366
Heffelfinger, H., 83, 367
G Heimberg, R. G., 15, 26, 70, 89, 176, 361
Heninger, G. R., 7, 365
Gabel, J., 34, 361 Hennig, J., 56, 363
Gaffney, G., 34, 361 Hermans, D., 60, 366
Gagnon, F., 5, 19, 20, 63, 69, 70, 107, 149, Hill, C. L., 7, 100, 133, 365
365, 368 Hirsch, J., 154, 366
Gerard, D., 58, 362 Hiss, H., 113, 314, 366, 373
Gershuny, B., 61, 364 Hodgson, R., 13, 15, 33, 38, 40, 96, 152,
Gibbon, M., 130, 363 175, 235, 334, 367, 369, 372, 373
Gigliotti, T., 33, 377 Hoehn-Saric, R., 35, 36t, 370
Gledhill, A., 20, 70, 175, 374 Hoekstra, R. J., 72, 104, 361, 367
Golding, J., 33, 368 Hohagen, F., 56, 115, 361, 367
Goldsmith, T., 40, 365 Hollander, E., 38, 41, 44, 46, 47, 55, 363, 367
Goldstein, A., 96, 364 Hoogduin, C. A. L., 113, 116, 363, 368
Goldstein, R. B., 35, 361 Hoogduin, K., 104, 115, 376
Goodman, W., 7, 26, 34, 47, 100, 133, 361, Hoover, C., 73, 367
365, 369 Horowitz, M. J., 65, 367
Gorbis, E., 150, 361 Huppert, J. D., 73, 135, 175, 249, 359, 364
Gorfinkle, K. S., 116, 374 Hwu, H.-G., 33, 35, 377
Götestam, K. G., 107, 191, 377
Grayson, J., 97, 99, 102, 150, 280, 331, 364, I
366
Greenberg, D., 30, 249, 366 Insel, T., 51, 55, 57, 73, 367, 377J
382 AUTHOR INDEX
Jaisoorya, T., 36t, 367 Lafont, S., 105, 362

Janardhan, R., 36t, 367 Lahart, C., 63, 365
Janavs, J., 130, 374 Landau, P., 114, 362
Janeck, A., 83, 361, 367 Lange, K., 58, 369
Janet, P., 38, 367 Langner, R., 135, 364
Javitch, J. A., 47, 363 Latimer, P. R., 102, 150, 331, 364
Jean, K., 70, 368 Lattimer, P., 97, 99, 364
Jeavons, A., 20, 374 Lax, T., 112, 368
Jefferson, J. W., 114, 366 Le Bars, D., 58, 362
Jenike, M., 58, 60, 147, 149, 361, 367, 369, Leckman, J., 7, 22, 26, 43, 47, 368, 369, 371
373, 374 Lecrubier, Y.,130, 374
Johnson, M. K., 60, 367 Lee, H. J., 12, 369
Jones, H., 250, 367 Leiberg, S., 135, 364
Jones, M. K., 88, 103, 175, 104, 368 Lelliott, P., 114, 115, 369
Lenz, G., 35, 362
K Letarte, H., 107, 149, 365
Levine, C., 110, 365
Kalsy, S., 70, 83, 359 Levis, D. J., 274, 375
Kampman, M., 116, 368 Levitt, J. ,T., 94, 109, 110, 145, 365
Karno, M., 33, 368 Levy, R., 96, 370
Katz, R., 114, 362 Lewis, B., 34, 361
Katzelnick, D. J., 114, 366 Liang, K.-Y., 35, 36t, 370
Keck, P. E., 43, 369 Libb, J. W., 62, 360
Keijsers, G. P. J., 116, 368 Liebowitz, M. R., 48, 102, 114, 115, 116,
Kendrick, A. D., 58, 374 363, 364, 374
Keshavan, M. S., 55, 373 Lindsay, M., 102, 369
Keuthen, N. J., 58, 374 Linnoila, M., 55, 367
Khanna, S., 73, 368 Liverant, G. I., 30, 366
Kichic, R., 135, 364 Lopatka, C., 71, 369
Kirk, J. W., 109, 368 Lopez-Ibor Alcocer, M. I., 56, 362
Kobak, K. A., 113, 114, 149, 154, 366, 369 Losee, M. C., 154, 365
Koch, W. J., 105, 146, 370 Luenzmann, K. R., 33, 65, 359
Kohlbeck, P. A., 60, 61, 370 Lynam, D., 70, 359
Kolada, J. L., 33, 368
Konig, A., 56, 115, 363, 367 M
Koran, L. M., 34, 368
Kosslyn, S., 60, 361 MacLeod, C., 61, 369
Kovacs, M., 61, 368 MacDonald, P., 61, 115, 369
Kozak, M., 7, 8, 22, 31, 32, 61, 94, 96, 98, Mackenzie, T., 40, 361
100, 102, 108, 109, 110, 113, 114, Magliana, L., 34, 369
115, 134, 145, 150, 191, 232, 251, Maidment, K. M., 150, 361
253n1, 257, 274, 304, 310, 315, Maltby, N., 24, 116, 376
359, 363, 364, 365, 366, 368, 375, Mandoki, M., 150, 374
376 Manzo, P. A., 149, 369
Kraanen, J., 96, 306, 363 Marasco, C., 34, 369
Krause, M. S., 30, 365 Marchand, A., 72, 376
Kwon, S. M., 12, 369 Marks, A. P., 100, 146, 363
Kyoon-Lee, C., 33, 35, 377 Marks, I., 34, 96, 112, 113, 114, 115, 149, 154,
Kyrios, M., 22, 30, 370, 375 235, 362, 366, 367, 368, 369, 372
Marks, M., 33, 65, 362
L Martens, K., 60, 366
Lachance, S., 70, 368 Martin, C., 47, 368
Ladouceur, R., 5, 11, 19, 20, 63, 69, 70, Masellis, M., 34, 369
107, 149, 183, 238, 331, 365, 368 Mataix-Cols, D., 58, 72, 113, 149, 360, 369
AUTHOR INDEX 383
Mathews, A., 70, 364 Note, I., 105, 362

Matthews, A., 60, 361 Novara, C., 74, 374
Mawson, D., 114, 115, 369 Noyes, R., 35, 361
Mayrhofer, Z., 35, 362 Nury, A. M., 114, 115, 361
Mazure, C., 7, 100, 133, 365
Mazziotta, J. C., 56, 58, 323, 360 O
McCauley, C., 175, 366
McDonald, R., 114, 369
O’Connor, K., 46, 72, 115, 371, 376
McDougle, C., 34, 361
Öst, L. G., 314, 371
McElroy, S., 40, 43, 365, 369
Ostenheider, M., 114, 370
McHugh, P. R., 34, 371
Ozarow, B., 95, 364
McIntyre, A., 114, 370
McKay, D., 22, 32, 48, 49, 315, 370, 371
McLean, P. D., 105, 156, 370 P
McNally, R., 35, 60, 61, 370, 373, 377
Mehta, M., 155, 370 Pahl, J. J., 56, 360
Menchon, J. M., 72, 360 Paradis, C., 110, 153, 365, 366
Mendelsohn, M., 135, 360 Parkinson, L., 65, 371
Menzies, R. G., 17, 18, 88, 103, 104, 175, Pato, C. N., 4, 371
362, 368, 370 Pato, M. T., 4, 114, 147, 371
Merkel, W., 72, 370 Pauls, D., 4, 26, 46, 47, 369, 371
Merkelbach, H., 5, 63, 71, 370, 373 Paulson, L. A., 56, 363
Meyer, V., 96, 370 Paya, B., 56, 362
Milby, J., 97, 364 Peindl, K. S., 33, 377
Miller, N. E., 38, 362 Pershad, D., 8, 73, 360
Miller, W. R., 152, 370 Persons, J. B., 109, 371
Mitchell, D., 20, 372 Peynirciglu, Z., 60, 373
Mock, J., 135, 360 Pfohl, B., 35, 361
Mollard, E., 105, 114, 115, 362 Phelps, M. E., 56, 323, 360
Molnar, C., 61, 364 Phillips, K., 40, 43, 133, 134, 363, 365, 369
Monteiro, W., 114, 115, 369 Pieters, G., 60, 366
Montgomery, S. A., 114, 370 Pifarre, J., 72, 360
Moore, J. G., 56, 363 Pigott, T., 60, 373
Moore, K., 33, 63, 64t, 65, 359 Pollard, C. A., 72, 370
Morrison, N., 70, 374 Port, J. D., 56, 377
Mouton, S., 40, 175, 375 Price, L. H., 7, 100, 133, 365
Mowrer, O., 38, 370 Provencher, M., 183, 365
Mueller, E. A., 55, 367 Pryzwansky, W. B., 121, 361
Muller, J., 58, 61, 370 Przeworski, A., 60, 70, 82, 364, 376
Munchau, N., 115, 367 Purdon, C., 33, 65, 69, 82, 83, 211, 359, 372
Muris, P., 5, 63, 71, 370, 373
Murphy, D. L., 55, 114, 147, 367, 371 R
Murphy, T. K., 150, 374
Rabavilas, A., 96, 242, 372
N Rachman, S., 4, 13, 15, 19, 20, 21, 23, 24,
25, 33, 38, 40, 57, 59, 61, 62, 63,
Nestadt, G., 34, 36t, 370, 371 64t, 65, 66, 69, 70, 73, 76, 79, 81,
Newman, S. C., 33, 368 83, 88, 96, 103, 149, 152, 175,
Newth, S., 21, 81, 371 176, 194, 235, 334, 367, 369, 371,
Neziroglu, F., 32, 48, 49, 370, 371 372, 373, 374
Nitescu, A., 55, 367 Radomsky, A. S., 22, 59, 61, 62, 370, 373
Nordahl, H., 72, 377 Rasche-Rauchle, H., 115, 367
Noshirvani, H., 114, 115, 369 Rasmussen, S., 7, 15, 33, 34, 35, 100, 133,
Note, B., 105, 362 134, 363, 365, 373, 375
384 AUTHOR INDEX
Rassin, E., 71, 373 Shapira, N., 40, 150, 365,374

Rauch, S., 147, 149, 369, 373 Shapiro, A., 46, 374
Rauner, M., 77, 360 Shapiro, E., 46, 374
Raye, C. L., 60, 367 Sheehan, D., 110, 136, 374
Rector, N. A., 34, 369 Sher, K., 63, 365
Rheaume, J., 5, 15, 19, 20, 26, 63, 70, 89, Shiraki, S., 34, 362
107, 149, 176, 361, 365, 368 Sica, C., 73, 374
Ricciardi, J. N., 35, 373 Silberschatz, G., 109, 371
Rice, D. P., 34, 362 Simpson, H. B., 116, 374, 375
Richards, C., 70, 83, 175, 373, 374 Skoog, G., 34, 375
Richards, J., 59, 361 Skoog, I., 34, 375
Richter, M., 7, 34, 61, 369, 375 Sluys, M., 114, 115, 362
Riddle, M. A., 35, 36t, 370 Smith, L. C., 110, 365
Riemann, B., 83, 367 Sochting, I., 105, 134, 146, 370, 375
Riggs, D. S., 70, 113, 364, 373 Sookman, D., 22, 370
Riley, S., 48, 376 Sorenson, S., 33, 368
Ristvedt, S., 40, 361 Spaan, V., 71, 373
Roberts, J. E., 58, 61, 370 Speck, O., 56, 363
Robillard, S., 115, 371 Spinhoven, P., 104, 115, 376
Rollnick, S., 152, 324 370 Spitzer, R. L., 130, 363
Romanoski, A. J., 34, 371 Srinath, S., 36t, 367
Roper, G., 15, 79, 373 Staebler, C. R., 72, 370
Rosen, J., 48, 373 Stamm, B. H., 241, 375
Rosen, R. M., 150, 361 Stampfl, T. G., 274, 375
Rosenberg, D. R., 55, 56, 363, 373 Stanley, M., 40, 375
Rowa, K., 83, 211, 372 Steer, R. A., 135, 360
Rozin, P., 175, 366 Stefanis, C., 96, 242, 372
Rowland, C. R., 34, 362 Steketee, G., 30, 34, 35, 68t, 70, 95, 97, 98,
Rubinstein, C., 60, 373 99, 102, 113, 149, 150, 151, 153,
154, 155, 202, 235, 280, 305, 331,
S 361, 364, 365, 366, 375, 376, 377
Stern, R. S., 114, 115, 369
Salkovskis, P. M., 12, 19, 20, 38, 48, 63, 65, Stewart, C. M., 56, 363
70, 73, 76, 77, 79, 83, 134, 175, Stiles, T. C., 72, 107, 191, 377
191, 330, 364, 373, 374, 377 Street, G., 59, 61, 82, 113, 150, 359, 376
Salzman, L., 38, 374 Suckow, R. F., 55, 367
Samuels, J., 34, 35, 36t, 370, 371 Summerfeldt, L. J., 7, 258, 375
Sanavio, E., 74, 374 Swann, A., 40, 375
Sarteschi, P., 114, 370 Swinson, R. P., 7, 36t, 360, 375
Sasson, Y., 57, 366 Synodi, D. S., 83, 376
Savage, C. R., 58, 374 Szuba, M. P., 58, 360
Saxena, S., 56, 374
Scarone, S., 59, 358
Schafer, J., 100, 146, 363 T
Schneider, D. J., 82, 377
Schlosser, S., 34, 361 Tallis, F., 13, 62, 274, 375
Schnurer, A., 96, 370 Taylor, S., 23, 48, 105, 134, 146, 193, 287,
Schulte, A. C., 121, 361 329, 370, 375
Schwartz, J. M., 56, 58, 323, 360 Teachman, B., 20,, 372
Schwartz, S. A., 7, 22, 23t, 31, 33, 40, 41, Thaler, F. H., 38, 374
42f, 48, 63, 64t, 65, 149, 359, 374 Thibodeau, N., 5, 19, 20, 63, 69, 70, 107,
Selin, C. E., 56, 323, 360 149, 365, 368
Serlin, R. C., 114, 366 Thienemann, M., 34, 368
Shafran, R., 17, ,18, 19, 20, 69, 70, 73, 176, Thomas, J. C., 110, 377
362, 372, 374 Thomas, N. D., 29, 376
AUTHOR INDEX 385
Thordarson, D., 69, 70, 105, 134, 146, 176, Warshaw, M., 34, 35, 375
370, 374, 375 Warwick, H. M., 48, 191, 374, 377
Thorpe, S. J., 79, 374 Watson, D., 30, 377
Todorov, C., 115, 371 Wegner, D. M., 82, 83, 377
Tolin, D. F., 24, 32, 59, 60, 61, 70, 73, 82, Weiller, E., 130, 374
83, 116, 175, 249, 268h, 354, 359, Weissman, M. M., 33, 35, 377
376 Wells, A., 83, 192, 377
Tosini, P., 34, 369 Wenzel, K. W., 154, 366
Towbin, K., 46, 371 Westbrook, D., 20, 374
Tran, G. Q., 113, 150, 151, 375 White, K., 154, 375
Trant, J., 20, 372 White, T. L., 82, 377
Trufan, S., 34, 361 Whiteside, S., 48, 56, 70, 83, 359, 377
Tsuang, M. T., 33, 373 Whittal, M. L., 105, 146, 370
Turgeon, L., 72, 376 Wiegartz, P., 33, 65, 359, 361
Turner, R., 97, 98, 99, 150, 331, 364 Wiener, R. L., 72, 370
Turner, S. M., 102, 375 Wig, N. N., 8, 73, 360
Wilhelm, S., 60, 377
U Williams, J., 130, 363
Williams, K., 153, 377
Urretavizcaya, M., 72, 360 Winkelmann, G., 115, 367
Wisner, K. L., 33, 377
V Wolpe, J., 274, 377
Wong, C., 38, 40, 41, 44, 46, 367
Van Balkom, A. J. L. M., 102, 104, 115, 376 Woods, C. M., 59, 60, 61, 73, 175, 358, 376,
van den Hout, M., 77, 360 377
Van Dyck, R., 104, 376 Worhunsky, P., 24, 116, 376
Van Noppen, B., 155, 376 Wroe, A. L., 70, 79, 175, 374, 377
Van Oppen, P., 102, 104, 105, 115, 208, Wu, K. D., 30, 377
274, 376
Vapnik, T., 150, 361 Y
Varma, V. K., 8, 73, 360
Veale, D., 48, 376 Yang, M. C. K., 150, 374
Verbank, M. J. P. M., 116, 368 Yao, S. N., 105, 362
Verma, S. K., 8, 73, 360 Yaryura,-Tobias, J. A., 32, 48, 49, 370, 371
Vevea, J. L., 59, 60, 61, 377
Vieweg, B., 134, 366 Z
Visser, S., 72, 104, 363, 367
Viswanathan, R., 110, 365 Zahner, G., 46, 371
Vitale, A., 7, 22, 369 Zapotoczky, H. G., 35, 362
Vogel, P. A., 72, 107, 191, 377 Zelaya, F., 58, 369
Zhang, H., 7, 22, 369
W Zitterl, W., 35, 114, 362, 370
Wahl, K., 79, 374 Zoellner, L., 75, 112, 115, 116, 287, 359,
Walker, D. E., 26, 47, 369 364
Ward, C. H., 135, 360 Zohar, J., 55, 57, 114, 147, 366, 370, 371,
Ward, H. E., 150, 374 377
Warren, R., 110, 175, 377 Zohar-Kadouch, R., 114, 147, 371
Subject Index
Note: f indicates figure, h indicates handout, t indicates table.
A Avoidance, 16, 21, 24–25, 28–29, 41, 43–44,

45t, 47t, 49t, 51, 53, 66, 74–75,
Abstinence violation effect, 313–314 87t, 88–90, 94, 103, 108, 123,
Activating event, 197, 224, 330 128–129, 131–132, 144, 146, 152,
Age, 33, 109, 153 154, 164, 176, 178–180, 183, 185,
Amplifying, 61, 281–282, 305, 324 188–189, 191–192, 201t, 202,
Antecedents, 20, 28, 38, 41, 45t, 46, 47t, 207–209, 212, 215–218, 240, 244,
197, 217, 310 247, 253, 255, 258, 264, 269, 271,
Anxiety disorders, 5, 35, 36t, 48–50, 52, 276, 281, 285, 302, 305–307, 313,
93, 109, 115, 128, 130, 138, 273 316–319, 324, 332, 334
Anxiety management training (AMT), passive, 81, 84, 85t, 164t
102 Avoidance prevention, 307
Anxiety-evoking
exposure tasks, 95 B
material, 238
obsessions, 15, 39 Biological
scenes, 247 abnormalities, 63
situations, 145, 198 markers, 55, 57
stimuli, 98, 200, 249, 306 models, 57
thoughts, 15, 17, 28, 39, 98, 239, 332 theory, 58, 140–141, 154–155
Assessment, 163–164, 164t, 165f, 168, 171, treatments, 143, 147
177, 179, 181, 185–186, 188, 191, Body dysmorphic disorder, 6t, 35, 36t,
198, 202, 217, 218t, 230–231, 48–49
239, 264, 283, 302, 304, 311–312, Brain
(see also Brown Assessment of chemistry, 190, 194
Beliefs Scale) circuits, 55–56
Autogenous obsessions, 12, 27 function, 58, 139–142, 158, 323
Automatic thoughts, 198–200, 201t, 330 structure, 4
386
SUBJECT INDEX 387
Brown Assessment of Beliefs Scale Cognitive-behavioral therapy (CBT),

(BABS), 132t, 133, 312, 346–348 92–93, 116t
Buying, 179, 210, (see also Compulsive advantages/disadvantages of,
buying) 159–161
as an adjunct to pharmacotherapy,
C 116–117
in combination with medication in
Case formulation, 143–144, 163, 185–186, treatment of OCD, 115–116,
187f, 188–189 161–162
Checking, 5, 7–8, 13, 14t, 15–16, 19, 22–25, comparison of with medications for
30–31, 37, 41t, 47–48, 58–63, 66, OCD, 113–115
73, 87t, 90, 94, 98, 122, 124, 127, effectiveness of, 108–110
129, 131–132, 134–135, 137–138, factors associated with the outcome
149, 152, 156, 159, 168, 181–182, of, 111–113
185, 193, 208–209, 216, 227, impact of (on functional disability),
243–244, 255, 259–260, 264, 269, 110–111
271, 289, 293–295, 301, 332 overview of, 143–147
Chemical imbalance, 84, 139, 194, 323 Comorbidity, 35–36t, 37, 46, 109–110, 115,
Cognitive 148t, 150–151
aspects of depression, 134 Compulsions, 6t, 7–8, 12–13, 32, 38–39,
biases, 70–71, 154 46, 131–132, 138, 219–220
challenges, 330–331 anxiety reducing, 15–16
change, 144, 329 caused by chemical imbalance, 323
deficit models, 58–63 checking, 98
distortions, 176, 186, 202–213, 324 cleaning, 25, 59, 90
features of global distress, 135 functional properties of, 15, 47t
interventions, 151, 192, 242, 275, maintenance of, 84
285–286, 291, 301–303, 309, mental, 182
313, 326, 330 nail biting, 44, 46
mechanisms of change, 274–275 origins, 63
model of emotion, 197–213 overt, 18–19
responses to triggers, 144, 168 predominant patterns of, 22
rituals, 16 primary, 14t
self-consciousness, 76 severity of, 133
specificity models, 66 sexual, 36t, 40
strategies, 324 skin picking, 44, 46
techniques, 110, 143, 150, 222–224, Compulsive
241, 249, 272, 301, 315, 317 behaviors, 5, 7–8, 11, 21, 26, 31, 38, 40,
theory of emotion, 67f 41t, 44, 56, 63, 80, 149, 164t, 205
therapy, 145–146, 159, 186, 319 buying, 36t, 44
Cognitive therapy (CT), 102–108, 191, nail biting. 44, 46
274, 298, 324, 331 praying rituals, 22
in addition to ERP, 107–108 rituals, 7–8, 12–13, 14t, 15–16, 20–21, 34,
delivery of, 103–104 40, 43, 46, 48, 50–51, 57, 63, 66,
versus ERP, 104–107 74–75, 77, 82, 89, 98, 122, 124,
Cognitive-behavioral model, 63–75, 129–130, 138, 144–146, 152,
78–80, 84, 86f, 144, 172–173, 186, 156, 159, 168, 176, 183, 185,
188, 192, 263, 265, 297, 300 189, 192, 204, 213, 220–223,
and intervention techniques, 152 254–255, 258, 264, 271, 273,
negative reactions to, 323 301, 311, 314, 334
and symptom dimensions, 86–91 sexual behavior, 39
treatment implications of, 90–91 Concealment, 21, 87t, 89, 183, 188,
Cognitive-behavioral theory of develop- 240–241
ment, 74, 188 of obsessions, 81–82, 85t
388 SUBJECT INDEX
Contamination, 63, 76, 81, 86, 87t, 88, 97, Emotion

104, 131–132, 153, 169, 171–172, cognitive model of, 197–213
175, 178–180, 186, 197, 207, 256, cognitive theory of, 67f
258–259, 261, 264, 280–283, 288, Emotional
290–291, 303, 305–308 arousal, 45t, 63
cultural influences in, 73 associated with intrusive thoughts, 49t
fears of, 21–22, 23t, 40, 49t, 69, attachment, 29
128–129, 137, 168, 245, 256, cognitive specificity model of, 66,
275–276, 332–333 197–213
obsessions, 7, 11–12, 24–26, 90 discomfort, 12
preoccupation with, 5 reactivity, 113, 150, 331
rituals, 94, 180, 258 reasoning, 18, 77, 85t, 207, 213
Counting, 14t, 16, 22, 24, 66, 179–181, 246, responses to triggers, 144, 168,
259–261, 310 197–199
Course of OCD, 33–34 significance, 75–76
Covert support, 155
attempts to seek reassurance, 255, 262 upset, 103
neutralization, 19–21, 49t, 85t, 116, Epictetus, 190
164t, 182–183, 238 Ex juvantibus reasoning, 57
rituals, 16, 27–29, 45t, 87t, 170, 172, Exposure and response prevention
176, 179, 182, 295–300 (ERP), 93–94, 96–98, 114–117,
form and function of, 13, 14t, 144–147, 151, 154, 191–192,
15–16 205–212, 222, 274–276, 307
sensitization, 95 the addition of CT to, 107–108
tactics, 8 delivery of, 94–95
efficacy of, 99–102
D exposure exercises in, 104
guidelines for, 277h
Danger cues, 76, 204 rationale for, 226–231, 249–251
Danger Ideation Reduction Therapy variations of, 109–113
(DIRT), 104 versus CT, 104–107
Debriefing, 275, 286–287, 300 Exposure therapy, 144, 150, 159, 160f, 161,
Decontamination behaviors, 25–26, 94, 124, 191, 207, 223t, 223, 225, 227,
180, 244–245, 258, 261, 290, 307 235, 274, 334
Delusional disorders, 51–52 for different symptom dimensions,
Depression, 19, 24, 30, 34, 40, 45t, 48, 66, 289–301
90, 103, 113, 115, 126, 132, 132t, early sessions, 275–287
134–137, 150, 161, 190, 202, 206, homework, 287–289
312, 331 later sessions, 302–303
Didactic style, 103, 191, 194, 195t, 309, 324 structure of, 275
Dismantling studies, 97–99 stylistic considerations, 303–308
Distraction, 11, 20, 79, 83–84, 179, 243,
261, 293, 302 F
Dysfunctional
assumptions, 104–105, 197–198, 330 Fear hierarchy, 225, 252f
beliefs, 67, 71, 75, 77, 81–82, 108, 150, developing, 230–242
164t, 173–176, 191–192, 222, Feared situations, 76, 93, 125t, 128, 145,
234, 241, 262–263, 278–280, 155, 175, 222, 223t, 228–229,
303, 316, 323, 326, 330 242, 259, 274, 327, 334
cognitions, 65–72, 91, 173, 186, 235, 317 Feedback, 21, 121, 136–142, 312
Female patients, 208, 295
E Fight-or-flight response, 59, 76–77, 212
Fixed beliefs, 31, 51
Ego-dystonic, 11, 52, 330 Functional
SUBJECT INDEX 389
abnormalities, 55–56, 58, 63 Incompleteness, 26–27, 31, 47, 86, 87t, 89,
assessment (of OCD symptoms), 163, 169, 172, 175–176, 179, 181–182,
164t, 165f–167f, 185 246, 261–262, 276, 300–301
disability, 132, 132t, 135–136, 147, 212 Information gathering, 143–145, 163–183,
impairment, 13, 34–35, 46, 110–111, 223t, 231, 239
135, 244 Interviewing techniques, 130, 152, 324
Functioning Intrusive thoughts, 5, 8, 12, 21, 28, 40,
cognitive, 147 48, 49t, 60, 63, 64t, 65–66, 67f,
improvement in, 111 67, 69–72, 74, 76, 78, 81,
interference with, 5, 6t, 40, 124, 133, 83–84, 89–90, 103, 105, 108,
177, 316 145, 164t, 175, 182–183, 192,
social, 127 194, 195t, 193h, 197–200,
209–211, 223, 238, 241, 248,
G 254, 271, 294, 295, 300–301,
313, 330–331, 334
Gambling (see Pathological gambling) In vivo exposure, 93, 97–98, 112, 145, 225,
Gender, 153 228, 231, 233–237, 247–248, 275,
Generalized anxiety disorder (GAD), 35, (see also Situational exposure)
49–50, 113, 150
Group therapy, 146, 152–153, 155, 313 K
Guilt, 4, 66–67, 71, 74, 82, 134, 169, 296
Kleptomania, 43
H
L
Habituation, 93, 324, 3269, 329, 331
Hand washing, 26, 66, 104, 126, 180, 188, Lapse, 146, 304, 309
260, 327 versus relapse, 314
Harming, 23–24, 86, 87t, 88, 169–170, 172, Lifestyle exposure, 307, 316–317
175, 178–179, 181–184, 200, 210, Losing control, 298
221, 227, 242–244, 248, 259–260, fear of, 135, 247
276, 291–292, 297, 301, 330–331 of thoughts, 82, 172
Hoarding, 8, 9t, 14t, 22, 23t, 29–31, 113,
135, 149, 169 M
Homework, 94, 102, 104–105, 107,
112–113, 115, 145, 189, 223t, 264, Maintenance, 314–319
267t, 273, 275, 287–289, 295, factors, 76–86
306–307, 316, 323 processes, 54, 75–76, 122, 144–145,
Homosexual obsessions, 172, 201t, 240, 152, 163, 186
247–248 Medications, 55, 93, 109, 113–117, 122,
Humor, 308 127, 136–140, 146, 148, 150–151
Hypervigilance, 25, 76–77, 85t, 188 advantages/disadvantages of,
Hypochondriasis (HC), 47–48 157–158
effectiveness of, 157
I Memory, 25, 61–63, 127
bias, 61
Imaginal exposure, 93–94, 98–99, 112, deficits, 58–59, 61–62
211–212, 225, 228, 238 Mental rituals, 7, 16–18, 22, 28–29, 51,
and the fear hierarchy, 239–240 78–79, 85t, 131, 149, 176–177,
preliminary, 242 182, 238, 254, 255t, 262, 300
primary, 240–241 Misinterpretation, 65–72, 81, 84, 90, 92,
secondary, 241–242 186, 202, 208, 211–220, 234, 238
types of, 238–239 of bodily sensations, 47
Impulse control disorders, 13, 36t, 39–46 foundations of, 72–74
390 SUBJECT INDEX
of thoughts, 52, 66, 103, 164t, 194, 295, characteristics of, 8, 9t, 10t, 11–12, 50t
301 concealment of (see Concealment)
defined by, 6t
N mild, 4
originate from normal experiences,
Nail biting (see Compulsive nail biting) 63, 65
Neuroanatomy, 55–56 pure, 149
Neurobiological theories, 56–58 senselessness of, 113
Neutralization, 6t, 11, 19–22, 28–29, 43, severity of, 34–35, 133–135, 149
45t, 49t, 50, 52t, 53, 56–57, 71, sexual, 41–42, 172,188, 197, 209, 240
75, 77–80, 85t, 86t, 108, 116, 135, versus sociopathy, 52–53
164t, 173, 176–177, 182–183, 189, violent, 52, 81, 172–176, 179, 247–248
192, 207, 209, 220–222, 225–226, Obsessive-compulsive disorder (OCD),
228, 238, 254–255, 255t, 260, 3–4
262, 271, 273, 295, 307, 330–331 according to the DSM-IV, 5, 6t, 7–8
Nonparaphilic sexual disorders, 40–43 approaches to (through history),
“Not just right experiences,” 26, 176, 181, 38–39
246 diagnosis of, 3–36, 123–130, 138
dysfunctional beliefs in, 68t
O etiological theories of, 139–142
females with, 33
symptom subtypes, 22, 23t, 23–31
Obsessional symptoms, 4–5, 17, 22, 27, 30–34, 46,
distress, 20, 25, 37, 39, 45t, 66, 75–79, 51, 55–58, 62, 131–139
80f, 92–93, 129, 162, 164t, severity of, 7, 132–134, 149, 312
168, 188, 255–256, 317 Obsessive-compulsive personality disor-
doubt, 168 der (OCPD), 27, 50–51
fears, 12–13, 15–16, 18–19, 21, 31–32, 38, Obsessive-compulsive spectrum disor-
40, 44, 51, 56, 59, 66, 69–70, 74, ders (OCSDs), 36t, 37–38, 41
78, 81, 84, 88, 90, 148, 150–151, Obsessive Beliefs Questionnaire (OBQ),
156, 159, 163–164, 185–186, 71, 174, 311, 351–356
189, 192–193, 204–206, Onset of OCD, 33
212–213, 250, 254–256, Ordering, 14t, 22, 26–27, 70, 87t, 89, 135,
269–273, 275, 283, 286, 291, 181
300, 302, 304–305, 307, 319, Outpatient treatment, 94, 96, 109–110,
323, 327, 333–335 145–146, 153
counterproductive effects of safety Overestimation of threat, 68t, 69, 78, 81,
behaviors on, 123, 129, 85t, 87t, 88, 96, 103–104,
213–222 173–175, 186, 202, 205–208, 241,
decreasing, 98 245, 333
related risks associated with, 104 Overvalued ideas (OVI), 31–32
stimuli, 93, 164t, 230–235, 275, 307, 315
attending to, 76 P
confronting, 276
identifying, 168–172, 176–183 Pathological gambling, 36t, 43–44
interpretations of, 173–176 Perceived threat, 47t, 48, 66, 76, 84
mistaken beliefs about, 251 Perfectionism, 26–27, 29, 31, 50, 68t, 70,
new interpretations of, 331 212–213, 257
purposeful responses to, 46 Pharmacotherapy, 55, 113–117, 143, 148,
triggers, 134 150, 152, 154–155, 157
Obsessions, 5, 7, 116, 122–124, 129, Placebo treatment, 101t, 102, 107, 114–115
131–132, 137–139, 162 Poor insight, 6t, 31–32, 146, 150, 161
anxiety-invoking, 15 Positron emission topography (PET), 56,
blasphemous, 152, 179 58
SUBJECT INDEX 391
Post hoc ergo propter hoc, 57 increased sense of, 62

Prevalence of OCD, 32–33, 35, 46, 63 inflated sense of, 67, 104, 245
Problem-solving therapy, 102, 145, 323 mentally induced, 61
Programmed exposure, 307, 316–317 for mistakes, 61
Psychoeducation, 94, 105, 123, 137, 144, overestimation of, 208
191–192, 194, 223, 226, 262, 323, Responsibility Attitudes Questionnaire,
330–332 175
Psychotic disorders, 51 Ritualistic behavior, 63, 84, 124, 258, (see
characteristics of, 52t, 109, 151 also Compulsive rituals)
Q S
Quality of life with OCD, 34–35, 110 Safety-seeking behavior, 12–21, 28, 37, 39,
48, 50t, 51, 52t, 52, 66, 69, 74–80,
R 80f, 82, 84, 85t, 88–97, 122–124,
128–129, 131, 144–145, 150, 152,
160f, 163, 164t, 168, 176–189,
Race, 153
207–209, 212–222, 230, 234, 241,
Randomized controlled trial, (RCT), 100,
247, 253–259, 263, 270, 273–274,
102, 104, 108–110, 114
276, 283, 285–286, 289, 300, 307,
Rational emotive therapy (RET), 104–105
314–315, 317–319, 322–329, 332,
Rationalizing, 3, 5, 11
334
Reactive obsessions, 12
Schizophrenia, 51–52, 139, 327
Reassurance seeking, 5, 18–19, 28, 66, 77,
Self-perpetuating cycle, 16, 17f, 66, 83
79, 87t, 88, 226, 251, 254, 255t,
Serotonin
256, 262, 273, 283, 286, 291, 301,
hypothesis of OCD, 55, 57, 139–140
322, 325–327, 330
reuptake inhibitors (SRIs), 55, 57,
Rebound effect, 82
113–117, 143, 147, 157–158
Relapse, 114, 152, 251, 306, 309, 314–315,
Sexual
319
impulses (unwanted),7, 12
prevention, 75, 144, 146, 154
obsessions, 9t, 10t, 21, 27, 41–42, 172,
process of, 145
188, 197, 209, (see also Ho-
Repeating, 14t, 22, 24, 26, 28, 51, 87t,
mosexual obsessions)
88–89, 181–182, 244, 261, 301
thoughts (unwanted), 5
Repetitive behavior, 4, 6t, 7–8, 11, 13, 14t,
Sheehan Disability Scale (SDS), 110–111,
15–16, 37–41, 42f, 43–44, 45t,
135
46–49, 51, 52t, 76, 78, 137,
Single photon emission computed topog-
180–181, 216, 250, 255
raphy (SPECT), 56–57
Residential treatment, 146–147, 149,
Situational exposure, 93, 97, 99, 228,
152–153
238–249, 254, 284–285, 291, 293,
Response prevention, 95, 287, 307, 318,
301, (see also In vivo exposure)
327
Skin picking, 39, (see also Compulsive
designing plan for, 255–259, 270f, 271,
skin picking)
282
Social support, 148, 155, 314–315, 320
ending, 310–311
Socratic dialogue, 103–104, 191–194, 195t,
help with, 260h
206, 209–210, 213, 222–224, 263,
rationale for, 253–255
285, 300, 303, 311, 319, 324, 329
for unwanted thoughts, 262
Subjective resistance, 11, 51
Responsibility, 87t, 174
Subjective units of discomfort scale
appraisals, 66–67
(SUDS), 236, 236h, 237, 251,
cognitions, 88, 176
275–276, 280–284, 295–301
for disasters, 300–302
Superstitious behavior, 3, 5
for harm, 23, 63, 103, 169, 181, 186, 202,
Symptom dimensions, 7–8, 23, 30–31, 58,
220, 241, 246, 258, 291, 332
67, 76, 87, 164, 172, 174–175,
392 SUBJECT INDEX
183, 242, 253, 259, 262, 276, U

289–290, 330
Unacceptable
T sexual behavior, 5
Testing, 182 thoughts, 12, 14t, 17, 20–22, 23t, 27–29,
Thought-action fusion (TAF), 67, 68t, 37, 43–44, 63, 76, 89–90, 107,
69–71, 87t, 88, 105, 176, 131, 168–172, 176, 179, 182,
208–210, 247 197, 209, 211, 240, 247–249,
Tics, 13, 46–47, 47t 254, 262, 276, 295
Therapeutic Uncertainty, 76, 170, 181, 204–205, 239,
effectiveness, 54 281
exposure, 145, 273, 276, 303 everyday levels of, 285
relationship, 92, 122, 151, 191–193, intolerance of, 70–73, 87t, 88, 164t,
224, 229, 256 175–176, 186, 202, 242, 244,
Thought 246, 301
control, 8, 11, 68t, 69, 73, 89–90 managing, 227, 275
paradoxical effects of, 82–84
suppression, 5, 11, 20, 28, 42, 53, V
82–83, 183, 188, 211, 298, 300
Threat (see Overestimation of threat and Violence, 65, 69–70, 198
Perceived threat) objects used to commit, 65
Tourette’s Syndrome, 13, 36t, 46–47 reading about, 247
Treatment thoughts of, 22, 27, 52, 78, 103,
aim of, 54, 171, 251, 285 170,172, 177
availability of, 154 words associated with, 179
development of (behavioral), 95–96
effective, 34 W
for OCD, 31
ending, 309–314
implications, 90–91 Worry, 49, 50t, 50, 52, 70, 74, 81, 83, 89,
history, 109, 148t,151–152, 336–338 129t, 130, 141, 150, 161, 199,
options, 143, 155–162 222, 296–299, 312, 325, 330
successful, 28, 57–58, 75, 93, 314
Trichotillomania (TTM), 39–40 Y
females with, 40
Triggers, 40, 41t, 47t, 144, 168–170, 179, Yale-Brown Obsessive Compulsive Scale
185, 188, 197, 202, 217, 238–239, (Y–BOCS–SC), 7–8, 13, 22, 131
242, 247, 307

Jonathan S. Abramowitz - Understanding and Treating Obsessive-Compulsive Disorder. A Cognitive Behavioral Approach (2005)

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What is the book about?

What is the book about?

What cognitive-behavioral techniques are discussed in the book?

What cognitive-behavioral techniques are discussed in the book?

Understanding and Treating

LAWRENCE ERLBAUM ASSOCIATES, PUBLISHERS

Copyright © 2006 by Mayo Foundation for Medical Education and

Lawrence Erlbaum Associates, Inc., Publishers

Library of Congress Cataloging-in-Publication Data

ISBN 1-4106-1571-5 Master e-book ISBN

To the memory of my grandparents:

About the Author ix

I: WHAT WE KNOW ABOUT OCD

1 Recognition and Diagnosis of OCD 3

2 Differential Diagnosis: What Is OCD and What Is Not? 37

3 What Causes OCD? 54

4 The Maintenance of Obsessions and Compulsions 75

5 Overview of Cognitive-Behavioral Therapy for OCD 92

II: HOW TO CONDUCT CONSULTATION

6 Consultation I: Diagnosis and Assessment 121

7 Consultation II: Recommending a Treatment Strategy 143

8 Information Gathering and Case Formulation 163

9 Cognitive Therapy: Education and Encouragement 190

10 Treatment Planning I: Rationale and Hierarchy Development 225

11 Treatment Planning II: Response Prevention, Support, 253

12 Conducting Exposure Therapy Sessions 273

13 Wrapping Up and Following Up 309

14 Addressing Obstacles in Treatment 322

Appendix A. OCD Treatment History Form for Assessing 335

Appendix B: The OCD Section of the Mini International 338

Appendix C: Yale–Brown Obsessive Compulsive Scale 340

Appendix D: The Brown Assessment of Beliefs Scale 345

Appendix E: The Obsessive-Compulsive Inventory– 348

Appendix F: The Obsessive Beliefs Questionnaire 350

Appendix G: Interview on Neutralization 356

Author Index 379

Subject Index 386

Jonathan S. Abramowitz, PhD, is an Associate Professor of Psychology at

Obsessive–compulsive disorder (OCD) has captured the attention of

are “compulsive”) in response to obsessional fear. Studies also demonstrate

als should delineate the essential principles of assessment and treatment

Salkovskis, their elegant writings have also had a major bearing on my

Few emotional disorders are as devastating as obsessive–compulsive dis-

Sarah’s obsessions and compulsions seem like extraordinary phenom-

patient sample reported occasional intrusive unwanted thoughts, the con-

OCD ACCORDING TO THE DSM–IV

According to the Diagnostic and Statistical Manual of Mental Disorders (4th

A. Either obsessions or compulsions.

which obsessional thoughts have become the focus of concern; compulsive

One of the most striking features of OCD is its heterogeneity—obsessions

Characteristics of Clinical Obsessions

It might be tempting to label any kind of repetitive thought or preoccupa-

Category n % Case Example

Note. Up to three primary obsessions were identified for each patient.

Form Characteristics Case example

SAFETY-SEEKING BEHAVIOR: COMPULSIONS

Salkovskis (1991) defined safety-seeking behavior as behavior that is per-

Overt Compulsive Rituals

Category n (%) Case Example