The Nature of Obsessive Compulsive Disorder: The Basic Phenomena

This is the first part of a series of blog posts that I will be writing regarding the nature of OCD. This first blog post aims to introduce the basics for those who are interested in learning some of the theory behind the phenomena. Please stay tuned for further updates regarding cognitive theories,  prevalence, what keeps OCD cycling, cognitive distortions and thinking errors, treatment options and relapse prevention.

A good understanding of the basic phenomena, to what obsessions are and the nature of how compulsions relate to obsessions is crucial for working effectively with service users with OCD. In my experience of offering training courses on OCD and working with this client group, there seems to be confusion over the basics, which is not exclusive to the general population, but also health care professionals. The following blog post aims to introduce the basics of OCD, the theories and provide examples of how it all fits together.

Obsessions

Obsessions are involuntary and often described as unwanted, intrusive thoughts, images, impulses or urges that are regarded as repugnant, senseless, unacceptable and very difficult to dismiss. Obsessions are accompanied by intense feelings of anxiety and discomfort, and an urge to ‘neutralise’ the thoughts (Salkovskis, 1999).

Intrusive thoughts have been researched extensively and regarded as universal, are experienced by those without a diagnosis of OCD or complaint of anxiety and are not thought to be problematic (Freeston et al., 1991; Rachman & de Silva, 1978; Salkovskis & Harrison, 1984). However, for those with OCD marked distress is common.

Rachman (2003) outlines the core, classical obsessions as aggressive/harm, sexual or blasphemous in nature and is common to experience more than one theme and explains how obsessions are regarded as ‘ego-dystonic’. This means that the obsessions are contrary to the person’s beliefs about themselves, their morals and what they find socially acceptable. It is understandable, knowing that obsessions are as far removed from the person’s own sense of being, that one might experience intense anxiety, and attempt to neutralise the intrusive thought or attempt to prevent the thought from entering one’s mind again.

Compulsions

Compulsions are voluntary, and often regarded as ‘neutralising’ behaviours that are carried out to offer temporary relief from the discomfort and anxiety caused by the obsession (Rachman, 2003). Although compulsions are seen as entirely voluntary behaviours, to the person experiencing obsessions the need to ‘neutralise’ is not seen as voluntary but vital to avoid catastrophic events or harm coming to self or others, or to minimise the impact of any obsessions they fear they might have carried out.

Compulsions can take the form of both overt (visible) and covert (unseen) behaviours, such as hand washing (overt) or mentally praying repetitively (covert) (Rachman, 2003). As overt rituals are easily seen, it is easier to recognise the possible symptoms, but for those who experience purely covert rituals it can be a little more difficult to detect.

There are two further forms of neutralising behaviours that are theorized. The concepts of Verification and Restitution has been widely discussed and researched. For people seeking verification, they may neutralise in order to prevent anything “bad” from happening, e.g. cleaning rituals to prevent cross contamination or spread of germs, or checking doors to ensure they are secure. Secondly, Restitution neutralising may be performed when one becomes convinced that something “bad” has already occurred or they fear they might have caused harm, and the neutralising behaviours take form to minimise its impact and put things right (Cougle et al, 2007).

Examples:

Obsession: “I might not have turned the gas off properly, the house might blow up and I will lose all of my belongings, because of my carelessness”.

“If I don’t check the gas, it might be left on and I will be responsible for the house blowing up, and if people are in next door, they could be killed by my careless behaviour and I will go to prison”.

Compulsion: Repeatedly checking the gas hob or switch is off and checking the oven for the smell of gas (overt compulsions/rituals and verification).

Obsession: “What if I am potentially a psychopath and I might want to harm my own children”

Repetitive intrusive images of harming one’s own children.

Compulsion: Avoiding spending time with children or avoiding motherly/fatherly roles or hiding or eliminating objects that are potentially weapons from ones home e.g. sharp knives (this is a non exhaustive list of examples).

Obsession: “How do I know I haven’t put poison into my mum’s cup of tea?”

Compulsion: Pour the cup of tea down the sink and make a new cup (overt, restitution), or avoid making drinks altogether (covert).

The case of ‘false memories’

It is not uncommon for those who live with OCD to experience ‘false memories’. A false memory is an event that one might believe has took place, but is nothing but imaginational. False memories can seem very real and understandably can heighten anxiety. Needless to say, false memories cause anxiety because intrusive thoughts, images, impulse or urges are never pleasant in nature, and when one becomes frightened that they may have played out something heinous and terrible, it starts the process of restitution and reassurance seeking behaviours.

 

*Note to healthcare professionals – obsessions are ego-dystonic and not a true reflection of the person who experiences them and there has never been a single case of anyone undertaking any single obsession or intrusive thought. Obsessions are as far removed from the person’s morals and values that the mere thought of these creates intense anxiety and fear. People who experience intrusive thoughts/obsessions are not at any risk to harming themselves or others.

References

Cougle, J., R., Lee, H. and Salkovskis, P., M. (2007) “Are responsibility beliefs inflated in non-checking OCD patients?” Journal of Anxiety Disorders. 21 (1) pp. 153-159.

Freeston, M. H., Ladouceur, R., Thibodeau, N., & Gagnon, F. (1991). “Cognitive intrusions in a non-clinical population: I. Associations with depressive, anxious, and compulsive symptoms”. Behaviour Research and Therapy, 29, 585–597.

Rachman, S., & de Silva, P. (1978). “Abnormal and normal obsessions”. Behaviour Research and Therapy, 16, 233–248.

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

Salkovskis, P. M., & Harrison, J. (1984). “Abnormal and normal obsessions: A replication”. Behaviour Research and Therapy, 22, 549–552.

Salkovskis, P. m. (1999). “Understanding and Treating Obsessive Compulsive Disorder”. Behaviour and Research Therapy. 37, Supp. 1 S29-52

The Wellness Toolbox

This toolbox was developed specifically for service users that attend the Obsessive Compulsive Disorder (OCD) support group that I run, and is tailored very much to OCD but can be very easily used with a variety of other mental health problems.

What is a Wellness Toolbox?

 

A wellness toolbox is a folder full of information on what kinds of things will help to keep you well. These things are information about your mental health problem, coping strategies, activities that you enjoy, goals for the future and information on what may trigger anxiety and what to do in times of crisis.

A wellness toolbox is very individual as different people enjoy different things, and people are inherently individual. But what a toolbox like this can offer you is a snap shot of things to draw upon for the times when we feel we may be unwell or becoming unwell, and having a resources file to draw upon can help us to focus more.

Knowledge is Power

As part of your wellness toolbox, it is useful if you can gather information all about what you are experiencing, about your mental health problem and anxiety.

You may even wish to write about your positive experiences, your achievements and goals for the future (hierarchy of fear, life goals etc…). When goal planning, it is always useful to imagine a long term goal, but to break that down into small and achievable steps in order to meet it in the future.

Knowledge is the key to understanding OCD and by doing this, it can help you realise that it is not only you who is experiencing these thoughts, images, impulses, urges or doubts, especially in the times when you are alone.

Coping Strategies

It is always useful to have a few resources at hand for times when you feel anxiety creeping upon you, or when you need to wind down.

Examples

  • Going to the gym
  • Walking the dog
  • Reading a book
  • Spending time with family
  • Writing a journal/creative writing
  • Getting rest and relaxation/stress reduction exercises
  • Listen to music
  • Speak to my doctor/therapist
  • A list of social networks for support

Triggers

It is crucial to understand the things that can trigger OCD and anxiety, and being aware of these triggers can prepare you for them or equip you with the knowledge on how to avoid a crisis.

Examples

  • Alcohol and drugs
  • Stressful activities
  • Arguments
  • Not enough sleep
  • Certain dates and anniversaries
  • Low mood
  • Stress
  • Increased responsibilities
  • Poor memory

 

Trigger Action Plan

What would help you if one of your triggers came up? What has worked in the past for you, and what has worked well for others?

Examples:

  • Speaking to a friend/peer counselling
  • Doing some breathing exercises
  • Taking time out

 

Crisis Planning

A crisis plan is something that is very individual. It details:

  • How you are and feel when you are well
  • Signs for you or others to watch for if becoming unwell
  • Support networks to access
  • Advice for yourself and others on how to help in these times of crisis (or advice on what others can avoid doing that may make your situation worse).