As with the other disorders discussed in this book, the integrative model of OCD is a diathesis-stress model emphasizing biological and psychological factors (Barlow & Durand, 2015); part of the diathesis component of this model is the person’s biological vulnerability to experience anxiety. Indeed, findings of studies examining twins or the rates of disorders among family members have provided some evidence that OCD tends to run in families (e.g., Billett, Richter, & Kennedy, 1998; Black, Noyes, Goldstein, & Blum, 1992; Fyer, Lipsitz, Mannuzza, Aronowitz, & Chapman, 2005; Hettema, Neale, & Kendler, 2001). This dimension was somewhat evident in Pat, who did not recall a family history of OCD but did indicate a history of panic disorder in her first-order relatives. This provided evidence that Pat may have had a biological tendency to experience anxiety.

Although Pat could not recall any life events that contributed to the onset or increase in her OCD symptoms, the integrative model underscores stress’s importance in the disorder’s origins. For example, research has shown that a stressful situation may not only trigger unexpected panic attacks (see Case 2) but also mark an increase in the frequency of both intrusive, unpleasant thoughts and ritualistic behavior (e.g., washing, checking) (Parkinson & Rachman, 1981a, 1981b). Stress may trigger these symptoms, but it is insufficient to produce full-blown OCD. In other words, although many people experience intrusive thoughts or ritualistic behavior after being exposed to stressful life events, most do not go on to develop OCD (Fullana et al., 2009).

So what factors determine whether these initial symptoms develop into OCD? As in other anxiety disorders (such as panic disorder), the integrative model asserts that anxiety focused on the possibility of experiencing additional symptoms is a central factor in the cause of OCD. Specifically, a person with some intrusive thoughts in response to life stress may be anxious about having more of these thoughts because he or she perceives them as dangerous or unacceptable. Consequently, the person attempts to suppress these thoughts. However, suppression has the opposite effect of increasing their frequency or intensity, a phenomenon that has been supported by research evidence (e.g., Najmi, Riemann, & Wegner, 2009; Salkovskis & Campbell, 1994). These points are consistent with cognitive models of OCD that underscore the position that people who believe some thoughts are unacceptable or dangerous are at greater risk for developing OCD (Salkovskis, 1985, 1989; Shafran, Thordarson, & Rachman, 1996; Steketee & Barlow, 2002).

The integrative model addresses why some people may develop anxiety over experiencing additional OCD symptoms such as intrusive thoughts. Consistent with ideas expressed in cognitive conceptualizations of OCD (e.g., Salkovskis, 1989; Steketee & Barlow, 2002), the model specifies that these individuals may have had previous experiences that have taught them to perceive some thoughts as dangerous or unacceptable. This would represent a psychological diathesis or vulnerability to developing OCD. For example, a person raised in a devoutly religious family may hold strong beliefs about the appropriateness and acceptability of thoughts relating to such areas as sex and abortion. These individuals may respond with considerable distress to having thoughts of this nature. The negative perceptions of obsessive thoughts may often take the form of exaggerated assumptions about whether actual harm can result from the intrusive thoughts themselves (e.g., a thought about something can cause it to happen) and about the degree of personal responsibility for preventing harm to oneself or others (e.g., failure to prevent harm relating to the thought is just as bad as causing the harm directly). These features were evident in Pat, who equated the idea of contamination with the distinct risk of contracting germs that could be passed between herself and her family. This type of cognitive vulnerability has been termed thought-action fusion (Shafran et al., 1996), a specific risk factor for OCD that describes the tendency to believe that thinking about a disturbing event increases the likelihood of its occurrence and thinking about a disturbing action is morally equivalent to actually carrying it out (e.g., a highly religious person who believes that thinking about abortion is the moral equivalent as having an abortion).

Although compulsions (e.g., washing, checking) and other attempts at neutralizing obsessional material (e.g., repeating phrases, words, or prayers) contribute to the DSM-5 definition of OCD, they are also considered to be the phenomena that maintain the disorder over time. For example, although Pat’s excessive handwashing would often result in short-term relief (e.g., her panic attacks would subside after she washed), it maintained her problem over the long term by preventing her from disconfirming her predictions regarding the risk and anticipated harm of being contaminated (e.g., she never learned that washing was not necessary to prevent contamination). The patient’s social environment can also contribute to the maintenance of OCD. Pat’s family often acquiesced to her compulsive symptoms. Examples include her husband’s compliance with her demands to take her “contaminated” purse out of the house and her family’s agreement to allow Pat to keep separate food and dishes.

Question 5

Which theory for this case study is the treatment plan based upon? Please select the best answer.

Psychoanalytic theory
Diathesis-stress model theory
Cognitive theory
Behavioral theory