Understanding OCD Through Cognitive Models

The cognitive model for anxiety disorders, as delineated by experts such as Clark (1986) for Panic Disorder, Clark and Wells (1995) for Social Anxiety Disorder, and Salkovskis (1985) for OCD, has demonstrated a profound clinical impact on specific disorders. This impact persists despite the supposed neurological differences in different anxiety disorders postulated by researchers like Gray and McNaughton (to take but one example).

The effectiveness of these treatment models, nested in the cognitive theory of anxiety disorders (see Clark, 1999), is potentially attributable to their influence on an underlying sensitivity to threat (i.e., selective attention to threatening stimuli, physiological arousal, and subsequent performance of safety-seeking behaviors), often associated with trait Neuroticism. Such reasoning would certainly align with the transdiagnostic treatment protocols (e.g., Barlow et al’s [2017] unified protocol), which purport to address underlying tendencies across these various disorders.

While some may contend that OCD should not be classified as an anxiety disorder from a neuropsychological standpoint, the evidence for an inherent tendency towards anxiety in individuals with OCD is compelling. The cognitive model’s emphasis on threat sensitivity provides a valuable lens through which to view and treat OCD, offering insights that extend beyond traditional neuropsychological classifications.

Also, think about this for a moment: if the neuropsychological framework is informative for OCD, why can we not conjure up reasons for the postulated non-normative efficacy of psychopharmacotherapy in OCD? Supposedly, SSRIs can work for OCD but take a longer time and require a higher dose than other anxiety disorders. Could it not be that these effects are explained better with other explanations (e.g., the placebo effect is one contender & SSRIs exerting an effect on comorbid depressive symptoms is another contender). 

Regardless, it is not obvious that the neuropsychological frameworks are of service for our patients and thus it may be worth investing more resources in furthering our understanding of the cognitive processes and mechanisms of change in OCD (instead of funding neuropsychological studies in abundance at the cost of better understanding the treatment that actually works). Moreover, investment in novel treatment delivery for OCD patients might give funders way more “bang for their buck” than continuing down the neuropsychological path. 

Let’s remember that OCD is for all intents and purposes an anxiety disorder!

The cognitive model’s application to OCD highlights the disorder’s complex relationship with anxiety, suggesting that future research and treatment approaches should continue to explore these underlying connections. As such, it may have been premature and misguided to separate OCD from the anxiety disorders. At least one cannot help but to ponder this question, especially given the fact that no meaningful advancements in theraputic understanding of OCD has been made since this seperation (and if we use clinical guidelines as an anchor point, no advances in treatment have been made for two decades; cf. clinical guidelines for OCD have remained unchanged since 2005).

Let’s do better.

References and further reading

Barlow, D. H., Farchione, T. J., Bullis, J. R., Gallagher, M. W., Murray-Latin, H., Sauer-Zavala, S., Bentley, K. H., Thompson-Hollands, J., Conklin, L. R., Boswell, J. F., Amantia Ametaj, Carl, J. R., Boettcher, H. T., & Cassiello-Robbins, C. (2017). The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders Compared With Diagnosis-Specific Protocols for Anxiety Disorders. JAMA Psychiatry, 74(9), 875–875. https://doi.org/10.1001/jamapsychiatry.2017.2164

Bream, V., Challacombe, F., Palmer, A., & Salkovskis, P. (2017). Cognitive behaviour therapy for obsessive-compulsive disorder. Cognitive Behaviour Therapy for Obsessive-Compulsive Disorder., xviii, 281–xviii, 281.

Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24(4), 461–470. https://doi.org/10.1016/0005-7967(86)90011-2

Clark, D. M. (1999). Anxiety disorders: Why they persist and how to treat them. Behaviour Research and Therapy, 37, S5–S27. https://doi.org/10.1016/S0005-7967(99)00048-0

‌Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment. (pp. 69–93). The Guilford Press.

Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure and Response (Ritual) Prevention for Obsessive Compulsive Disorder: Therapist Guide (2nd ed.). OUP USA.

McNaughton, N., & Gray, J. A. (2024). The Neuropsychology of Anxiety. In Oxford University Press eBooks. Oxford University Press. https://doi.org/10.1093/oso/9780198843313.001.0001

National Institute for Health and Care Excellence (NICE). (2005). Obsessive-compulsive disorder and body dysmorphic disorder: Treatment (Clinical Guideline No. CG31). https://www.nice.org.uk/guidance/cg31

Rachman, S. (2003). The Treatment of Obsessions. Oxford University Press.

Salkovskis, P. M. (1985). Obsessional-compulsive problems: A cognitive-behavioural analysis. Behaviour Research and Therapy, 23(5), 571–583. https://doi.org/10.1016/0005-7967(85)90105-6