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Obsessive-Compulsive Disorder has two components,Obsessions and Compulsions, though not everyone with OCD identifies with having both. Many people will report compulsions without obsessions: “I just feel like I have to do it”, or, “I just have to do it until it ‘feels just right’”. Another group report obsessions only: “I just can’t get the thought out of my head”. When these obsessions do occur, they tend to have common themes, usually involving: violence; sex; and religion. Clinically speaking, obsessions are intrusive thoughts or images that are distressing. The most common obsessional themes are cleanliness, doubts about safety, order & symmetry, and aggressive, horrific or sexual imagery. Sometimes the person realizes that the thought is not logical or 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 reasonable obsessions that other people would agree should be of concern: “what if the lamp cord will start an electrical fire?” Compulsions are rituals used to decrease the distressing anxiety produced by the obsessions. Common among the compulsions are cleaning or washing rituals and checking. 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. The vicious circle of obsessions and compulsions is like a monster that demands to be fed or a bully that demands your lunch money. 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 immediate internal response of mental compulsion of trying to neutralize or reject the thought or is like the spontaneous and regrettable act of yanking on opposing ends of a string in order to get a knot out. 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 distress and amount of disruption associated with the symptoms. There is one and only one empirically supported treatment for OCD and that is Exposure with Response Prevention, with research showing 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 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. In order for the exposure to be effective it must be frequent and prolonged. The exposures can be graded which increases compliance and success. In order for the response prevention to be effective it must be total response prevention. 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 he no longer fears the contact. 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. For example, those with excessive worries about germs must not only stay in contact with "germy" things, but must also refrain from ritualized washing. 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 goal of ERP is to tolerate increasing amounts of uncertainty. 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).” |
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