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Obsessive-Compulsive Disorder
And Treatment Issues

By Carol Edwards



OBSESSIVE-COMPULSIVE DISORDER (OCD) HAS TWO ESSENTIAL CHARACTERISTICS: OBSESSIONS AND COMPULSIONS. Intrusive thoughts come into one's mind involuntarily and are the trigger for obsessions. External stimuli, such as coming into contact with dirt, can also trigger obsessional fears. Compulsions are the behaviours people do to make the obsessions go away.




Obsessions include contamination fears, an intolerance to asymmetry and imperfection. Other obsessional fears include being gay, transgender, a paedophile, or having mistaken intentions to hurt others or oneself. These are known as pure-intrusive thoughts or pure O. Also, one's attention to a specific part of the body and its functioning can cause a lot of distress. Such awareness is known as a somatic obsession. The heart beating and fearing it is irregular is another example of it; also, breathing, eye-blinking, staring and a crawling sensation on the skin.




Compulsions include checking, straightening, praying, ruminating, reassurance-seeking and washing. However, what the person doesn't know or trust yet is that such actions are not the long-term solution to ridding themselves of the thoughts they cannot control. Even when they are aware, it is hard for them to give up the compulsions because it's a temporary solution despite that it's the wrong one. They get anxiety relief momentarily, but unfortunately, the actions do not make intrusive thoughts go away. Instead, compulsions reinforce that there is a real danger when there isn't. Consequently, the problem keeps going in a circle, strengthening the obsession, making it more challenging to manage.




Doctors sometimes prescribe medication to people who have OCD. It is usually one of the selective serotonin reuptake inhibitors (SSRIs) that are also for depression. Since serotonin levels in the brain are decreased in OCD and depression, SSRI medication helps to maintain a more balanced level. Consequently, it supports better mood and reduces obsessive thoughts by up to sixty per cent. In that case, it acts well as an adjunct to active therapy for many people.


Active Therapy


Cognitive-Behavioural Therapy (CBT) and Exposure-Response Prevention (ERP) are therapies that are used to treat OCD. CBT helps change irrational thoughts, feelings and behaviours for better outcomes and helps prepare for ERP. The latter is the well-known evidence-based therapy designed to prevent the actions people do in response to intrusive thoughts. For instance, when people do ERP, they agree to face their fears in small steps - this is exposure. When facing obsessions, they further agree to resist compulsions - this is response prevention. Over time, it helps them build a tolerance for anxiety and leads to reduced symptoms or remission.


The process of habituation is the desired effect in ERP, showing that a person has understood the connection between developing fear related to the obsession and doing compulsions to reduce it. In other words, they see that performing rituals increases fear and that such actions need to be prevented to break that connection, hence becoming less sensitised to the obsession. However, habituation doesn't mean numbing one's anxiety is the actual goal in and of itself since anxiety is rooted in nature. Instead, to reach recovery or remission means one has to practise the methods used in treatment to break the connection noted above and then maintain their gains. In that case, a therapist usually provides a client with a relapse-prevention blueprint after a course of treatment.

When ERP Doesn't Have The Desired Effect


One thing to consider is that not all people take well to ERP. For example, cognitive therapy is sometimes more suitable for people struggling with emotional contamination fears because it's primarily a reasoning problem. I discuss this in my tutorial 'How To Overcome Non-Contact Contamination Fears'. Other times, when clinical depression prevents treatment from moving forward, active therapy might need to be put to one side until the person feels better.


More specifically, when people become overly preoccupied with their obsession and ritualising, it can affect treatment progress. For example, suppose a person is struggling with false desire in OCD. In a situation like this, it can affect the process of habituation. In other words, people can become so immersed in the obsession that imaginative involvement can shift the problem to a term described as dissociation peculiar to OCD (Soffer Dudek et al., 2018). First, absorption is the repressed attempt (ritual) to prevent a perceived threat from happening. The more someone does the rituals, the deeper the absorption becomes; hence habituation being affected. My tutorial 'How To Manage Dissociation' discusses this concept in more detail. When a deeper level of absorption becomes a problem, enhanced treatment methods can help bring a person back to the ERP process and, more importantly, the here and now.

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