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Section 14
Cognitive-Behavioral Treatment Part One

Question 14 | Test | Table of Contents

Obsessions often take the form of unwanted, repugnant thoughts that are a profound violation of the individual’s morality and values. Few studies actually examine prevalence of obsessions according to content, so published rates of repugnant obsessions are few. In a sample of 44 patients, 50% had aggressive obsessions and 32% had sexual obsessions (Rasmussen & Tsuang, 1986). Patients who have aggressive and unacceptable obsessions tend to exhibit the greatest symptom severity, when compared to individuals who have contamination, symmetry, or hoarding obsessions (Abramowitz, Franklin, Schwartz, & Furr, 2003). However, cognitive-behavioral treatment has been as effective for this subtype of obsessive-compulsive disorder (OCD) as it has for all other symptom subtypes (except hoarders, who responded less well to treatment than the others).

The manifestation of OCD is highly idiosyncratic, and individuals who have OCD typically use a variety of strategies to manage their obsessions and compulsions, depending upon situational factors, mood state, and expectations about what will be most effective in a given set of circumstances (Ladouceur et al., 2000). It is important, then, to ensure that a detailed understanding of each client’s OCD is achieved before developing a treatment plan (Salkovskis, 1999). Therefore, it is worthwhile to review the phenomenology of repugnant obsessions.

Phenomenology
Examples of repugnant obsessions include thoughts, images, or impulses of harming an innocent or helpless loved one (e.g., throwing a baby off a balcony, kicking an elderly person, swerving into the next lane while driving); sexual obsessions (e.g., thoughts of touching someone else sexually against his or her will, images of sexually molesting one’s baby); and obsessions that violate religious beliefs (e.g., images of having sex with Jesus, swearing in church, committing sinful acts). Repugnant obsessions can also take the form of doubt, such as "Did I run over someone without realizing it?" or "What if I didn’t check the baby food jar lid for dents carefully enough and the jar I used was dented and contains botulism, which survived the cooking process, and I’ve accidentally poisoned my child!" Examples of doubts about sexuality include "Am I gay but I haven’t realized it yet?", "Did seeing that [repugnant] image arouse me sexually?", "What if I molested my baby!" Religious doubts include "Have I offended God?", "Did I just sin?", "Did I contaminate that prayer with an impure thought?"

Repugnant obsessions tend to give rise to compulsive rituals of thinking a "good" or "safe" thought, engaging in ritualized and excessive prayer, and, most frequently, performing some form of checking (e.g., Abramowitz et al., 2003). Checking can take various forms, including the following:
• Checking that harm has not occurred (e.g., scouring the newspaper and television for reports of hit-and-run accidents, closely monitoring one’s body for signs of sexual arousal)
• Checking to ensure that harm will not occur (e.g., checking that the knives are safely in the knife block and that the car is to the right of the yellow line)
• Seeking reassurance, which is a form of checking by proxy

Obsessions that take the form of a doubt tend to give rise to reassurance. The reassurance can be manifested as self-reassurance—for example, rationalization (perusing homosexual pornography on the Internet and attempting to determine whether one is more aroused by it than by heterosexual pornography, scouring religious texts to determine whether a particular action or thought was sinful)—and as reassurance seeking, for example, asking child every few minutes whether he/she is feeling well, asking a close friend or spouse whether he/she thinks one is gay or perverted. Often the goal of reassurance is to obtain 100% certainty as to whether the obsession is accurate. Some patients report that they would feel relief even if they were to determine that the obsession is accurate because they would then be certain as to how to proceed. For instance, if a person knew he/she was definitely a pedophile he/she could arrange for someone else to care for a child and thus feel less conflicted about assigning care.

Repugnant obsessions are also associated with significant avoidance of thought triggers and targets of the repugnant obsessions. Examples include avoiding places where there are knives, food preparation, care of a child, driving, certain colors (e.g., red because it is associated with blood), contact with members of the same sex, religious ceremonies, and temptations of sin. Triggers for the obsession can become quite generalized (Rachman, 1998), such that a person with obsessions of stabbing his son may begin to avoid all sharp objects.

In addition to avoidance of external thought triggers individuals who have OCD engage in strenuous attempts at internal avoidance of the thought or attempts to suppress the thought.

Why Repugnant Obsessions Persist: The Cognitive-Behavioral Model
According to cognitive models obsessions give rise to negative appraisal that evokes distress and drives compulsive acts, suppression, and avoidance. Three different types of appraisal play an important role in the persistence of repugnant obsessions:
• Overvalued appraisals of responsibility (e.g., "any influence over outcome = full responsibility for outcome," "failing to prevent harm is just as wrong, morally, as actually causing harm") (Salkovskis, 1989, 1999)
• Thought–action fusion (e.g., "The more I have this thought the more likely it is to come true," "Having a morally repugnant thought is the moral equivalent to committing a morally repugnant deed") (Rachman, 1997, 1998)
• The importance of thought control (e.g., "Failing to control thoughts is a sign of mental weakness and instability," "Failures in thought control potentiate loss of control over any or all other domains of functioning") (Purdon & Clark, 1999)

Individuals who have repugnant obsessions may also be very concerned that the thought is evidence that highly repugnant personality characteristics are emerging and may become dominant (e.g., "Maybe I am a homicidal maniac at heart!") (Purdon & Clark, 1999).

Other kinds of appraisals and predictions can certainly play a role in OCD. Often beliefs about the need to engage in rituals can be important targets in therapy (e.g., "If I don’t perform the ritual I will be plagued by the thought continuously and eventually will have a nervous breakdown") (Wells, 1997). Appraisals about becoming anxious (e.g., "Anxiety is dangerous") can maintain compulsions for some clients (Freeston, Rheaume, & Ladouceur, 1996). Some patients have difficulty engaging in treatment because of their appraisal of what it would mean to recover from OCD; for example, they may believe "It would mean that my life has been wasted for the past X years," or "If I get better now it means that all the rituals I do are meaningless and I will look like a fool." It is useful to examine these fears and predictions and evaluate them realistically.

This appraisal leads to a negative affective state, and the compulsive ritual is performed to ameliorate that state. Any reduction in the ameliorative state or any appraisal that the affective state will escalate if the ritual is not performed serves as negative reinforcement for its performance. Ritual performance can increase distress, especially if the person is unable to achieve the desired state (e.g., of feeling reassured, of having "undone" the ritual, of having prevented harm). Furthermore, even if the ritual does not always lead to relief, it typically has offered some relief at least some of the time, and therefore its use is intermittently reinforced, and intermittent reinforcement schedules are, of course, the most difficult to extinguish. In order to avoid having the obsession altogether, and hence avoid the negative affective state and the need to engage in the ritual, individuals who have OCD avoid obsession triggers, stimuli that make the affective state more intense, and avoid the obsession itself (e.g., engage in thought suppression).

Avoidance ensures that there is no new learning about the obsession. Furthermore, thought suppression leads to hypervigilance to thoughts and thought cues, which is mentally exhausting. Inevitable failures in thought control during suppression are likely to enhance the appraisal that the thought is meaningful and requires control.
-Purdon, Christine. Wiley Periodicals, Inc. J Clin Psychol/In Session 60, 2004.

What is Obsessive-Compulsive Disorders?

International OCD Foundation. What You Need to Know About Obsessive Compulsive Disorder. International OCD Foundation, 2014.

Personal Reflection Exercise #7
The preceding section contained information about cognitive-behavioral treatment of repugnant obsessions. Write three case study examples regarding how you might use the content of this section in your practice.

Update
Cognitive Behavior Therapy
for Obsessive-Compulsive Disorder
in Routine Clinical Care:
A Systematic Review and Meta-Analysis

Öst, L. G., Enebrink, P., Finnes, A., Ghaderi, A., Havnen, A., Kvale, G., Salomonsson, S., & Wergeland, G. J. (2022). Cognitive behavior therapy for obsessive-compulsive disorder in routine clinical care: A systematic review and meta-analysis. Behaviour research and therapy, 159, 104170. https://doi.org/10.1016/j.brat.2022.104170

Peer-Reviewed Journal Article References:
Correa, J. K., & Sandage, S. J. (2018). Relational spirituality as scaffolding for cognitive-behavioral therapy. Spirituality in Clinical Practice, 5(1), 54–63.

Curling, L., Kellett, S., & Totterdell, P. (2018). Cognitive analytic therapy for obsessive morbid jealousy: A case series. Journal of Psychotherapy Integration, 28(4), 537–555.

Liggett, J., & Sellbom, M. (2018). Examining the DSM-5 alternative model of personality disorders operationalization of obsessive–compulsive personality disorder in a mental health sample. Personality Disorders: Theory, Research, and Treatment, 9(5), 397–407.

Olatunji, B. O., Ebesutani, C., & Tolin, D. F. (2019). A bifactor model of obsessive beliefs: Specificity in the prediction of obsessive-compulsive disorder symptoms. Psychological Assessment, 31(2), 210–225.

QUESTION 14
What are three different types of appraisal that play an important role in the persistence of repugnant obsessions? To select and enter your answer go to Test.

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