A comparison of flooding and thought stopping in the treatment of obsessional neurosis

Flooding in vivo and thought stopping were compared in patients with obsessional neurosis, in a cross-over design. It was hypothesized that the two techniques would have different effects on symptomatology. However, although both seemed to be effective treatments, there were no significant differences between them. Reasons for this finding are discussed. There was, however, a slight tendency for flooding to produce more overall improvement, and a greater reduction in avoidance behaviour. There was also a tendency for the first treatment to produce more effect. A worthwhile clinical finding was that a fair amount of improvement occurred after only eight out-patient sessions.     

Cleanliness Is Next to Godliness: Religiosity and Obsessiveness

Within the field of psychology of religion there has been increasing interest to test established theoretical perspectives with empirical data. One such initiative is concerned with examining theories derived from Freud and has examined the relationship between religiosity and obsessionality. This initiative has become increasingly complex, using a variety of different measures of both religiosity (attitude, practice and orientation) and obsessionality (personality traits and symptoms). The findings can be summarized: More positive religious attitude and greater frequency of religious practice are associated with higher scores on measures of obsessional personality traits, but not with scores on a measure of obsessional symptoms. Further, the limited data on the relationship between religious orientation and obsessionality is contradictory.     

Towards a comprehensive treatment for obsessional thoughts

A systematic treatment approach for obsessional thoughts is proposed. It is based upon an analysis of the chain of convert events and incorporates the distinction between the obsessional idea or fear and the cognitive rituals which follow. Systematic Disruption of covert rituals and Cognitive Restructuring of obsessional ideas are included within the treatment programme. The application of this approach is demonstrated with three cases treated for severe obsessional thoughts and followed up after 2 years.     

Time series analysis of obsessional behavior and mood during self-imposed delay and response prevention

Time series analysis of more than a year of daily self-report of three subjects showed that self-imposed delay and response prevention was effective in decreasing obsessions and compulsions. The subject-controlled treatment had a varied effect on mood—anxiety decreased in two subjects, but depression increased in one. (A similar worsening of mood after elimination of obsessional behavior was found in a previous case study.) Apparently, successful treatment of obsessional behavior will not necessarily lead to an improvement in mood. Concurrent mood symptoms need to be targeted separately; and, plans should be made to deal with mood symptoms that may occur once obsessional behavior is removed.     

The exclusion of the other2

The author begins by noting that the subject of obsessions and obsessional neurosis seems to have fallen out of favour with the analytic community in spite of the important part it played in the formation of Freud's theories, and notwithstanding the significance of its mechanisms in the maturation of the ego. He then discusses some theoretical considerations regarding the development of the taboo on touching and, by extension, contact. Attention is drawn to the parallels with autistic functioning emphasised by other authors. Particular importance is attached to the distinction between internal and external reality that arises during the anal‐sadistic phase and that leads to polarisation and splitting in obsessional neurosis. Following a discussion of the transference' countertransference situation with obsessional patients and of their concretistic experience in the treatment situation, as also featured in the literature, an extensive case history exemplifies the author's contentions and shows how the patient concerned developed during the course of his analysis. After pointing out the importance of the avoidance of identifications as a mechanism of obsessional defence, the author concludes the paper with a brief comparison of obsessional and hysteriform functioning and a characterisation of the obsessional defence as the excessive recourse to perverted thought functions so as to ward off paranoid anxieties.     

Causing harm and allowing harm: a study of beliefs in obsessional problems

This study investigates two factors hypothesised as relevant to obsessional problems because of the way in which they influence decisions whether or not to act to prevent harm. These are (i) the way in which intrusive thoughts increase the internal awareness of harm, and confront the person with the possibility of taking action to prevent such harm and (ii) the extent to which there is some obvious external factor which increases awareness of the possibility of preventing harm. Obsessional patients, anxious and non-clinical controls completed a scale which systematically measured these factors across a wide range of situations. Results across all situations evaluated confirmed previous findings that both obsessionals and nonobsessionals were more likely to report acting to prevent harm when awareness of it is prompted by an intrusion than when it is not. It was also found that participants in all groups acted more ‘obsessionally’ when a scenario is described in ways which suggest that harm may be by ‘commission’ than when it is described in terms of an ‘omission’. When scenarios about which each individual is most disturbed were analysed, anxious and non-clinical controls continued to differentially rate omission and commission situations; as predicted, this differential was not present for obsessional patients.

It is concluded that obsessionals are more sensitive to omission than are nonobsessionals when considering scenarios about which they are concerned, and that this sensitivity is one factor influencing the decision whether to act to prevent harm.     

Are prepared fears less severe, but more resistant to treatment?

In order to investigate the relationship between the extent to which clinical fears are prepared and clinically relevant characteristics of these fears (i.e. severity, age of onset and treatment outcome). the records of 63 obsessional and phobic patients were examined. Four independent raters scored the usable records (N = 55) on preparedness. The preparedness scores were combined and related to objective indices of severity (patients' scores on the Fear Survey Schedule, the Zung Depression Scale and the Maudsley Obsessional-Compulsive Inventory, as well as the treatment duration), onset ages and treatment outcomes (pre-treatment minus post-treatment MOCI scores, for a subsample of obsessional patients only). In contrast to earlier studies, it was found that product-moment correlations among preparedness ratings were relatively low and that prepared fears did not make up a majority in the sample. Indices of severity either did not correlate at all or correlated negatively with preparedness ratings. The positive correlation between preparedness and onset ages reached borderline significance. Evidence suggestive of a resistance to treatment of prepared fears was obtained.     

Assessment and treatment of obsessional harassment

Obsessional harassment and stalking have become increasingly recognized as significant social problems, often with dramatic negative repercussions on the lives of victims. As the public awareness of this problematic behavior has grown, the amount of clinical attention and empirical research focused on understanding the perpetrators of harassment has increased accordingly. Nevertheless, relatively little research has addressed the numerous issues involved in the assessment and treatment of obsessional harassment offenders. This article reviews the existing research on obsessional harassment/stalking, and offers a diagnostic typology of these offenders based on the nature of the relationship with the victim and the motivation of the offender. Treatment modalities are then discussed with regard to each of the primary diagnoses that occur among obsessional harassment offenders. Finally, strategies for initiating treatment for unmotivated or unwilling offenders are discussed, along with clinical issues that arise in the evaluation and treatment process.     

Obsessional Disorders: A Developmental Systems Perspective

The paper resumes the discussion of obsessional disorders in view of developments that have followed the 1965 Congress of the International Psychoanalytical Association when the last systematic analytic discussion of the Obsessional Neuroses took place. The paper reexamines principal contributions to that congress in an attempt to understand the failure of psychoanalysis to favorably influence the course of these disorders. It notes the subsequent findings of a burgeoning field of child observation that have called attention to the larger infant-caregiver constitutive system within which the intrapsychic phenomenology of the obsessional neuroses is produced and maintained. It draws attention to the crucial impact of the analyst and his causal theories, insufficiently recognized at the lime, in the co-determination of the course and outcome of analytic treatment and proposes a contextual systems approach to the reconfigured understanding of normal and pathological development.

The paper discusses the special role of cumulative trauma in the infant-caregiver system on the formation of enduring obsessional and compulsive patterns. It suggests that in the traumatic developmental system, endangerment to the self and unbearable pain are ever-present threats lo the child, and protective strategies, including importantly the processes of pathological accommodation, occupy a primary motivational status. It describes the automatic shaping of subsequent experience by the internalization of such processes in template formation. Freud's emphasis on aggression and unconscious guilt in the pathogenesis of the obsessional neuroses system is reexamined in the light of the contextual perspective proposed, and a clinical excerpt is offered to illustrate the thesis of aggression and guilt as contextual products of a traumatic developmental system. Special considerations that enter into the reconfigured analytic treatment of obsessional disorders are proposed, and some observations follow about problems commonly encountered in the new approach.

The paper argues for the systematic extension of the quintessential psychoanalytic tools of empathic-introspective investigation and illumination into the contextualization of inner experience in a fresh approach to the psychoanalytic treatment of these disorders.     

Converting a Freudian analysis into a Jungian one: obsession,addiction, and an answer from Job

In his analyses of obsessional patients, Sigmund Freud suggested that they suffered from intrusive cognitions and compulsive activities. Early psychoanalysts delineated the phenomenology of obsessionality, but did not differentiate what is currently termed obsessive‐compulsive disorder from obsessional personality. However, it was widely recognized that the success of psychoanalysis with obsessional patients was limited due to rigid characterological defences and transference resistances. The present paper examines the case of a middle‐aged obsessional academic who had been treated for nearly twenty years in a ‘classical' Freudian psychoanalysis prior to entering Jungian analysis. It examines how persistent focus on Oedipal conflicts undesirably reinforced the transference resistance in this obsessional man, and suggests that focusing instead on diminishing the harshness of the super‐ego via the therapeutic alliance, and fostering faith in the salutary aspects of unconscious processing has led to salutary results in this case. The biblical book of Job is adopted as ancient instruction in how to address the scrupulosity and addictive mental structuring of obsessionality in analysis.     

Treating Scrupulosity in Religious Individuals Using Cognitive-Behavioral Therapy

Scrupulosity, the obsessional fear of thinking or behaving immorally or against one's religious beliefs, is a form of obsessive-compulsive disorder that has been relatively understudied to date. Treating religious patients with scrupulosity raises a number of unique clinical challenges for many clinicians. For example, how does one distinguish normal beliefs from pathological scrupulosity? How does one adapt exposures to a religious patient whose fears are related to sinning? How far should one go in exposures in such cases? How and when does one include clergy in treatment? We address these issues and report a case example of the successful treatment of an ultra-Orthodox Jewish woman using the treatment principles that we recommend for religious individuals with scrupulosity.     

The spontaneous decay of compulsive urges

An experiment was carried out on eleven obsessional patients who complained of compulsive checking rituals. Exposure to a provoking situation produced marked anxiety/discomfort and strong urges to check. With minor exceptions, execution of the appropriate ritual was followed by marked decreases in anxiety/discomfort and urges. The results were interpreted as being consistent with an anxiety/discomfort reduction hypothesis.

The spontaneous decay of anxiety/discomfort and urges was observed during a 3-hr response-prevention period. The greatest part of the discomfort and compulsive urges dissipated within an hour. Discomfort scores and urges ran a closely parallel course. Few resurgences of discomfort or urges were observed during the 3-hr observation period, and there was little sign of displacement checking activity.     

Cognitive-behavioural factors and the persistence of intrusive thoughts in obsessional problems

Jakes' critique fails to consider (i) the importance of appraisal of responsibility in initiating neutralising activity, and that (ii) obsessional patients negatively evaluate the occurrence as well as the content of intrusive thoughts. These factors are crucial because neutralising is presumed to be central to the development and maintenance of obsessional disorders. The current form of the hypothesis is outlined and recent data reviewed. Possible experimental investigations on the focus of therapeutic interventions are considered.     

Therapeutic neglect omission of individual treatment of secondary defective developments

The increasing application of group psychotherapy involves the danger that secondary defective developments which cannot be cured within the group, will be neglected. For these, a specific psychotherapy is necessary and particularly urgent since these cases show a tendency towards becoming chronic. Such cases include obsessional neurosis, situation phobia, nosophobia, occupation neurosis, expectation neurosis, psychogenic impotence, anorexia nervosa, and compulsive vomiting. Secondary defective developments in the majority part of patients who consult a psychotherapist. As fear neuroses, they have to be separated from wishful neurosis (hysterical neurosis). There is an urgent need for psychotherapists to be trained and given continued training in the treatment of secondary defective developments so as to be able to treat such patients.     

Primary obsessional slowness: a nursing treatment programme with a 13-year-old male adolescent

A 13-year-old male adolescent inpatient with a 5-year history of primary obsessional slowness was treated using a nursing intervention programme involving prompting, pacing and shaping, or participant modelling of four types of self-care behaviour. The treatments produced an immediate increase in response rate of three of the four behaviour targets. Treatment gains were not maintained during the gradual fading of the intervention programme. Possible reasons for failure to achieve treatment maintenance are discussed in light of the literature on primary obsessional slowness.     

Responsibility attitudes and interpretations are characteristic of obsessive compulsive disorder

The cognitive-behavioural theory of Obsessive Compulsive Disorder (OCD) proposes that a key factor influencing obsessional behaviour is the way in which the intrusive cognitions are interpreted. The present paper reports an investigation of links between clinical symptoms (of anxiety, depression and obsessionality) and responsibility beliefs. These beliefs include not only measures of general responsibility attitudes (assumptions) but also more specific responsibility appraisals consequent on intrusive cognitions. The characteristics of two new questionnaires specifically designed to measure these beliefs were assessed in patients suffering from Obsessive Compulsive Disorder, in patients suffering from other anxiety disorders and in non-clinical controls. The scales measuring negative beliefs about responsibility were found to have good reliability and internal consistency. Comparisons between criterion groups indicate considerable specificity for both assumptions and appraisals with respect to OCD. There was also good evidence of specificity in the association between responsibility cognitions and obsessional symptoms across groups, and that this association was not a consequence of links with anxiety or depressive symptoms. Although the two measures were correlated, they each made unique contributions to the prediction of obsessional symptoms. Overall, the results are consistent with the hypothesis that responsibility beliefs are important in the experience of obsessional problems.     

Tyranny of the obsessional character

This essay relates many of the unwelcome features of modern life to the increasing influence of obsessional personality traits. This influence is becoming more pronounced as civilization advances and comes to be increasingly reliant upon depersonalized mechanical and commercial systems. The result has been a glut of unwanted information, an exaggerated reliance upon computing and numbers, an overgrowth of bureaucracy, a discarding of intuitive wisdom in favor of calculative reasoning, a loss of simplicity, a jargonized language, and ultimately, the degradation of human relationships and of human beings themselves.     

Primary obsessional slowness

Although most examples of slowness observed in patients with obsessional disorders can be regarded as secondary to checking rituals, it is suggested that there is a real but rare dysfunction in which the slowness is primary. The proposal is supported by information from standardized interviews and small scale experiments on 10 obsessional patients who were severely handicapped by their slowness. Unsystematic results encourage the hope that this type of disorder is moderately responsive to a simple therapeutic programme of prompting, shaping and pacing.     

Prepared phobias and obsessions: Therapeutic outcome

Sixty-nine phobic and eighty-two obsessional patients, treated at the Maudsley Hospital, were rated for ‘preparedness’, the evolutionary significance of the content and behaviour of the disorder. Reliable ratings (r = 0.78 and 0.90) of the dangerousness of the object or situation to pretechnological man indicated that the content of the large majority of the phobias and obsessions are judged as evolutionarily significant. Degree of preparedness, however, did not predict outcome of therapy, suddenness of onset of the disorder, severity of impairment, intensiveness of the treatment received, or age of onset. Nor was there any significant relationship between preparedness and certain other variables in the obsessional sample: stimulus generalization, effect on life style, impaired reproductive capacity and abnormal personality. The implications of these findings for the hypothesis that human phobias and obsessions are prepared, and for the clinical usefulness of the concept of preparedness, are discussed.     

Evaluation of an inference-based approach to treating obsessive-compulsive disorder

This study evaluated an inference-based approach (IBA) to the treatment of obsessive-compulsive disorder (OCD) by comparing its efficacy with a treatment based on the cognitive appraisal model (CAM) and exposure and response prevention (ERP). IBA considers initial intrusions in OCD (e.g. "Maybe the door is open", "My hands could be dirty") as idiosyncratic inferences about possible states of affairs arrived at through inductive reasoning. In IBA such primary inferences represent the starting point of obsessional doubt, and the reasoning maintaining the doubt forms the focus for therapy. This is unlike CAM, which regards appraisals of intrusions as the maintaining factors in OCD. Fifty-four OCD participants, of whom 44 completed, were randomly allocated to CAM, ERP or IBA. After 20 weeks of treatment all groups showed a significant reduction in scores on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the Padua Inventory. Participants with high levels of obsessional conviction showed greater benefit from IBA than CAM. Appraisals of intrusions changed in all treatment conditions. Strength of primary inference was not correlated with symptom measures except in the case of strong obsessional conviction. Strength of primary inference correlated significantly with the Y-BOCS insight item. Treatment matching for high and low conviction levels to IBA and CAM, respectively, may optimize therapy outcome.