CT/ERP for OCD: Case Study
OCD & Cognitive Therapy (CT)/Exposure and Response Prevention (ERP)
Obsessive-compulsive disorder (OCD) is a type of anxiety disorder that is often comorbid with other anxiety disorders such as agoraphobia, panic disorders, other specific phobias (heights, water, germs, etc.), social phobias (crowds, strangers, etc.), and overall generalized anxiety disorder (Oltmanns, & Emery, 2010). The "obsessions" in OCD have to do with intrusive thoughts that sufferers cannot simply ignore or write-off as something unusual, and manifests the "compulsions," which are really a form of ritual to erase these thoughts away (Siev, Hubbert, & Chambless, 2010; Wilhelm et al., 2005). This becomes a vicious cycle known as "thought suppression," which is a way for OCD sufferers to try to stop thinking about intrusive or unwanted thoughts, and a way to suppress the emotions that come along with the thoughts, which ends in ritual and begins again when the thoughts return (Oltmanns, & Emery, 2010). Many of these thoughts have to do with the core beliefs of the sufferer about themselves, for example, someone with OCD may have a core belief that essentially they are a bad person which manifests itself as compulsive symmetry/perfection in his/her environment (Chosak, Marques, Fama, Renaud, & Wilhelm, 2009; Siev, Hubbert, & Chambless, 2010). The intrusive thought may be, "if everything is not perfect, than I am a bad person, and if everything is perfect then I am okay for now." The main groups of beliefs are, "inflated responsibility, overestimation of threat, overimportance of thoughts, need to control thoughts, need for certainty, and perfectionism." (Wilhelm, 2005)
There are many forms of therapy for OCD, such as Desensitization and Exposure, Exposure and Response, Relaxation and Retraining, Cognitive Therapy, and medication (Oltmanns, & Emery, 2010). The problem with some of these therapies (especially the ones using exposure) is the high drop-out rate and reluctance to even go to therapy in the first place; it is often a scary and jarring experience for OCD sufferers to face their fears head-on (Chasson et al., 2010; Wilhelm et al., 2005). For the purposes of this paper and case study, the focus will be on Cognitive Therapy (CT), which is cognitive therapy to reform maladaptive thoughts, as well as Exposure and Response Prevention (ERP), which is a prolonged exposure to situations that produce anxiety (Oltmanns, & Emery, 2010).
The cognitive part of CBT focuses on four key strategies, which are Psychoeducation, Cognitive Domains, Core Beliefs, and Relapse Prevention (Chosak et al., 2009). Psychoeducation involves familiarizing the patient with techniques of the therapy, key words (like distortion, ritual, core belief, etc.), setting an agenda for each session (such as going over homework first and then moving on to new topics) (Chosak et al., 2009). The therapist will also take this time to subtly assess the patients OCD symptoms, intrusions, their triggers, emotions, and any avoidance strategies that the patient has developed thus far (Chosak et al., 2009).
After this initial period, the second strategy begins with Cognitive Domains, or examining the patients distortions together and setting new homework for the patient to recognize these himself (Chosak et al., 2009). Some distortions that are taught to the patient include "jumping to conclusions, catastrophizing, should statements, and emotional reasoning," which are then discussed at length to try and give these any supported evidence that they are true and will actually happen instead of being an irrational thought (Chosak et al., 2009). Supported evidence usually means trying to get the patient to act like a "detective" and prove that the distortions are not causing anything bad to happen (Chosak et al., 2009); for example a patient who thinks that if they think the intrusive thoughts and get emotional they will have a heart attack, a good way to disprove that is to allow the patient to feel the emotion, and of course, they don't have a heart attack.
The next stage is tackling the patients Core Beliefs about themselves, and this comes toward the end of therapy because it is the most difficult subject for patients to talk about freely, as it is the root cause of the OCD, and shattering these Core Beliefs is a huge step in therapy (Chosak et al., 2009). The final step for the cognitive part of CT is Relapse Prevention, which includes an agenda for after therapy, preparing the patient for a lapse or relapse in OCD behaviors, revisit skills learned in...
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