Obsessive-Compulsive Disorders
OCD typically has two components, Obsessions and Compulsions, though not everyone with OCD identifies with having both.
Clinically speaking, obsessions are intrusive thoughts or images that are distressing to that individual. The thought itself is not the problem -- it is the reaction to the thought that is anxiety provoking. Embedded in the obsession there is often thought-action-fusion which is an erroneous belief that having the thought means that it is important, more likely, or somehow significant. There is also an inherent wish to not have the thought which also infuses it with a certain power.
The most common obsessional themes are worries about cleanliness, doubts about safety, fixation on order & symmetry, and aggressive, horrific or sexual imagery. Sometimes the person realizes that the thought is not logical nor as distressing to the average person: "I know that other people don't worry about getting HIV from touching a railing at the mall". Yet others struggle with seemingly reasonable obsessions that other people would agree should be of some concern: "What if the lamp cord will start an electrical fire?" Knowing others don't worry as much or that the "what if" is not likely does not reduce the anxiety.
Compulsions are rituals used to decrease the distressing anxiety produced by the obsessions. Common among the compulsions are cleaning or washing rituals and checking routines. Compulsions are a temporary way to neutralize the anxiety that the obsession creates and can be physical actions or behaviors or mental rituals. Less observable compulsions include avoidance of situations or settings which heighten the obsessions (such as not using a public restroom or having a loved one open the mail or lock the house), and reassurances like asking directly "Did I hit that person that was standing at the bus stop?", or mentally self assuring "I know that I did not write something blasphemous in that e-mail".
Though they may 'work' short term, paradoxically compulsions worsen and strengthen the OCD.
Some people will report compulsions without obsessions: "I just feel like I have to do it" or, "I have to do it until it 'feels just right'". For these individuals there is no conscious anxiety provoking thought which drives the behavior, just an irresistible need to engage in the ritual. These rituals are often elaborate and rigid (can't easily be changed) and can be time consuming. Sometimes, at least initially, it is easier to shorten or change the ritual than it is to give it up completely.
Another group of people report intrusive and distressing obsessions only: "I just can't get the thought out of my head". For these individuals there is no observable behavior or action taken in response to the thoughts. When these pure obsessions do occur, they tend to have common themes, usually involving: violence; sex; or religion and individuals may be prone to unwittingly reassure themselves, analyze, or attempt to mentally undo the thought. These mental maneuvers, along with trying not to have the thought, are in fact the unidentified ritual compulsion.
Compulsions of avoidance and mental reassurance are often hard to identify, as are mental attempts to not think or worry about the thought or image.
The essential feature which distinguishes diagnosable OCD from obsessions and compulsions which are helpful is not the content of what we think and what we do, but the level of anxiety and amount of disruption associated with the symptoms. Distress and the inability to manage or control the thoughts or behaviors are what signifies a clinical level of OCD.
There is one and only one empirically supported treatment for OCD and that is Exposure with Response Prevention. Research shows that ERP is successful in managing OCD in 85% of cases with an average improvement of 50-80%.
The practice of exposure with response prevention (ERP) involves systematic exposure to a hierarchy of situations (real or imagined) and total resistance to the urge to perform a response to neutralize the distress. ERP is facilitated by an understanding of 1)the irrationality of obsessions and/or compulsions and 2)the concept of short-term discomfort needed for long-term anxiety relief.
The technique of exposure is based on the fact that anxiety usually goes down after long enough contact with something feared. Thus people with obsessions about germs are told to stay in contact with 'germy' objects (e.g., handling money) until their anxiety is extinguished. The person's anxiety tends to decrease after repeated exposure until they no longer fear the contact. However, therapists prescribing ERP know that in order for the exposure to be effective it must be frequent and prolonged. Because no one is likely to tolerate high anxiety for a long time, the exposures can be graded which increases compliance and success.
For exposure to be of the most help, it needs to be combined with response or ritual prevention (RP). In RP, the person's rituals or avoidance behaviors are blocked and they are stopped from substituting a new neutralizing compulsion. For example, those with excessive worries about germs must not only stay in contact with 'germy' things, but must also refrain from ritualized washing or sanitizing. Therapists prescribing ERP know that in order for the response prevention to be effective it must be total response prevention, but also know ways make that task easier by creating obstacles.
Exposure is generally more helpful in decreasing anxiety and obsessions, while response prevention is more helpful in decreasing compulsive behaviors. Despite years of struggling with OCD symptoms, many people have surprisingly little difficulty tolerating ERP once they get started. The first few sessions of treatment involve the assessment of OCD, development of the hierarchy and treatment plan, and psychoeducation about ERP. Often some baseline charting is prescribed for the second session as a way to begin the habit of doing homework as part of the therapy.
Those willing to try ERP must first understand that the goal of ERP is to tolerate increasing amounts of uncertainty and that the goal is not stopping the obsessions or stopping the compulsions. The goal of ERP is not 'learning' that it is okay to not perform a ritual. The goal of ERP is not sharpening skills of self reassurance via using self-talk such as, "If a therapist is telling me to do this, it must be safe (and effective too)." The goal of ERP is to not react to the thought and by changing the behavior the feeling of anxiety will gradual diminish. Sometimes the thoughts will then become less prominent as a bonus.
An experienced therapist can help those with OCD identify the obsessions and rituals, devise creative practice scenarios for exposure, and teach ways to tolerate the stress of response prevention. Experienced therapists are familiar with common treatment obstacles and will tailor a plan that is individualized so that it will increase your chances of success. Therapists who do not prescribe ERP for OCD will not help you get relief.
