Anxiety and related disorders Case 5
Thought suppression and OCD
Problem statement: “What is the association between OCD and thought suppression?”
Learning goals:
I. What is OCD? (Diagnosis, sub-types, symptoms, etiology, consequences, comorbidities)
II. What are obsessions and compulsions and what are the two motivational dimensions?
III. What is thought suppression and how does it maintain anxiety disorders? (PTSD, OCD)
IV. How can normal and abnormal obsessions be distinguished?
V. How does catastrophic misinterpretation contribute to OCD?
What is OCD?
Definition
OCD is characterized by unwanted repetitive thoughts which become obsessions, sometimes
accompanied by actions which become compulsions. These compulsions (ritualistic behaviors) are
often used to relieve intense and unbearable anxiety.1
Obsessions, worry, intrusive thoughts, and depressive rumination2
Obsession = focus on fears and concerns that are unrealistic, irrational or imaginary.
→ Not part of the personality; there is a conflict between one’s needs and goals = ego-dystonic.
→ Lead to overt compulsions and can be judged as entirely unacceptable.
→ Specifics of obsessions:
o Thought-action fusion (TAF) bias and dysfunctional beliefs about importance/control
of thoughts.
o Cognitive self-consciousness
o Meta-worry
Worry = focus on everyday negative outcomes involving finances, work, family, health, etc.
→ One’s needs and goals are in common = ego-syntonic.
→ Specifics of worry:
o Deficits in attentional control
o Thought suppression
o Meta-worry
Intrusive thoughts = thoughts stuck in your head, causing distress.
→ The difference between “normal” and “abnormal” intrusions can be seen in differences in
intensity or severity (basis of the Cognitive-behavioral model of OCD):
Clinical obsessions are more frequent, distressing, unacceptable, subjectively
uncontrollable, resisted, and ego-dystonic than the intrusions in nonclinical samples.
Individuals with OCD are more likely to use compulsions and other maladaptive control
strategies in response to their obsessions: avoid perceived triggers, and exhibit thought-
action fusion and over-importance of thought control appraisals.
→ Intrusions are random, obsessions are triggered by internal or external events.
Depressive rumination = repetitive and passive thinking about the possible causes and consequences
of stressful events.
→ Obsessive rumination = obsessions without overt compulsive behavior. (e.g., questioning the
meaning of life repeatedly, the nature of the universe, whether bad things are about to happen, etc.)
1 YouTube: OCD & Anxiety Disorders: Crash Course Psychology #29 https://www.youtube.com/watch?v=aX7jnVXXG5o
2
Clark & González (2014). Obsessive-Compulsive Disorder; pp. 497-500, 503-513.
, DSM-V OCD 300.3 (F42)
A. Presence of obsessions, compulsions, or both:
Obsessions are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges, or images experienced as intrusive and
unwanted, and that in most individuals cause marked anxiety or distress.
2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to
neutralize them with some other thought or action (i.e., by performing a compulsion).
Compulsions are defined by (1) and (2):
1. Repetitive behaviors/overt compulsion (e.g., hand washing, ordering, checking) or
mental acts/covert compulsion (e.g., praying, counting, repeating words silently) that the
individual feels driven to perform in response to an obsession or according to rules
that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress,
or preventing some dreaded event or situation; however, these behaviors or mental
acts are not connected in a realistic way with what they are designed to neutralize or
prevent, or are clearly excessive.
B. The obsessions or compulsions are time-consuming (e.g., >1 hour per day) or cause clinically
significant distress or impairment in social, occupational, or other important functioning.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical condition.
D. The disturbance is not better explained by the symptoms of another mental disorder.
ICD-10 obsessions and compulsions must be present for ≥2 weeks and may not be pleasurable.
ICD-10 also makes distinction between a more obsessional or compulsive nature of OCD in patients,
and a mixed subcategory for patients who were equally obsessional and compulsive.
Why OCD was considered an anxiety disorder:
1. Most obsessions elicit subjective anxiety or distress
2. A compulsion is similar to an escape response and usually (not always) reduce anxiety
3. Like fears, obsessions are provoked by internal or external triggers
4. Reassurance seeking, threat overestimation, and other underlying beliefs are common in
anxiety and OCD
5. Avoidance and safety behaviors are clear in OCD and other anxiety disorders
6. Certain disruptive events can interfere or invalidate the compulsion
Subtypes
1. Sexual, aggressive, religious, or somatic obsessions and checking compulsions
2. Ordering, symmetry, and arranging
3. Contamination obsessions and cleaning compulsions
4. Hoarding
- This emphasizes (benadrukt) poor decision-making, lack of insight and beliefs about
the value of possessions that elicits pleasure and pride.
- This is now a separate disorder in DSM-V
Checking compulsions, ordering/symmetry/arranging and cleaning compulsions more INC/NJRE.
Epidemiology
Lifetime prevalence = 1-3%
Most prevalent age = 20–44-year-olds; least prevalent = 65+ years
o Lifetime prevalence 30-44 = 2.3%
o Lifetime prevalence 65+ = 0.7%
