Theoretical Formulations Behavioural And Cognitive Models

In the behavioural model for OCD neutral internal stimuli, such as thoughts and images, become paired with an anxiety-provoking stimulus as the result of learning experiences. Because these previously neutral stimuli now cause anxiety, the patient develops avoidance behaviours, which result in an immediate reduction in anxiety. This encourages further use of the avoidance behaviours, which in time become more stereotyped and develop into a compulsive ritual. The ritual limits exposure to the initial stimulus and therefore there is no opportunity for the anxiety associated with it to be extinguished. The behavioural model is supported by evidence that obsessions cause anxiety and that compulsions reduce it (Hodgson & Rachman, 1972). Behavioural treatment involves exposure to the initial stimulus (which is now feared), while encouraging the patient not to carry out any behaviours to avoid this exposure and is known as exposure and response prevention (ERP).

Beck's (1976) cognitive model of emotion states that it is the meaning of events not the events themselves that trigger emotions. He describes the thoughts in OCD as related to an action that patients believe they either should or should not have taken. Compulsions are the patient's attempt to reduce excessive doubts. Therefore the anxiety is related to the consequences of being in a situation or thinking a thought, not to the initial thought or situation.

Salkovskis, Forrester & Richards (1998) suggests that intrusive thoughts are a universal experience but can develop into obsessions because of the way obsessional patients interpret the occurrence or content of the intrusions. Normal intrusions are interpreted as conferring responsibility for harm or preventing harm. Salkovskis (1985) describes five characteristic dysfunctional assumptions of OCD patients:

• 'Having a thought about an action is like performing the action.'

• 'Failing to prevent (or failing to try to prevent) harm to self or others is the same as having caused the harm in the first place.'

• 'Responsibility is not attenuated by other factors (e.g. low probability of occurrence).'

• 'Not neutralising when an intrusion has occurred is similar or equivalent to seeking or wanting the harm involved in the intrusion to happen.'

• 'One should (and can) exercise control over one's thoughts.'

Because of these assumptions the individual is distressed by normal intrusions and therefore overt or covert neutralising responses develop. Neutralising prevents disconfirmation of the individual's feared belief. An example is when a mother has a thought that she might harm her baby. If she responds by doing a ritual or giving her baby to someone else to look after, she interprets this as meaning that her baby is only alright because she did the ritual or let someone else look after the baby. Therefore the important factors are the negative automatic thoughts and responsibility appraisals accompanying intrusive thoughts. This model suggests that treatment should focus on identifying and modifying the dysfunctional assumptions and automatic thoughts, seeing the pathology in OCD in the content of thoughts.

Reed (1985) proposes that OCD is related to impairment in the organisation and integration of experiences, and pathology in the form of thinking. In this model OCD results from the individual's attempts to overstructure his life to compensate for this impairment. Foa & Kozak (1985) also suggest that there is an information-processing disturbance as well as a thought content abnormality. They suggest that OCD sufferers cannot make appropriate inferences from information about danger or the absence of danger.

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