On Obsessive Compulsive Disorder: OCD Obsessions, Compulsions, Expressions, & Treatment
I recently attended an intensive professional training for the treatment of obsessive-compulsive disorder put on by the International OCD Foundation. There is a national shortage of treatment providers who specialize in OCD, so the International OCD Foundation is making significant efforts to reduce the shortage by providing professional trainings around the country. The recommended therapy for OCD is a type of cognitive behavioral therapy called exposure response prevention (ERP).
In obsessive compulsive disorder, a person finds themselves unable to dismiss or get rid of unwanted thoughts, ideas, or images in their minds. The person experiences anxiety and distress, which they try to rid themselves of by doing a certain action or ritual (compulsion). The compulsion can be either behavioral (e.g. washing hands due to a fear of being contaminated) or mental (e.g. repeating words, counting, or mental checking due to a fear of “bad thoughts”). OCD can be very distressing and time consuming.
OCD can look different with each person affected. The most common example is usually someone with a fear of germs who engages in compulsive hand washing. Although this is common, OCD can have many “expressions.” Some other examples of OCD could include unwanted thoughts about harming others or self and behaviors to prevent or make sure it didn’t happen (e.g. checking to make sure no one was hurt), the urge to have everything “just right” and arranging things a certain away, forbidden or taboo thoughts followed by mental rituals or reassurance seeking, persistent doubts about oneself or character (e.g. someone fears they weren’t sincere enough and excessively examines their feelings to make sure) , fears of going “crazy” (e.g. worry that panic symptoms will cause one to snap and researching online to disconfirm the fear), or moral and religious concerns (e.g. feeling the need to go to confession to confess things others would consider minor or irrelevant). The obsessions and compulsions may be related, meaning the action is logically connected to the fear (e.g. a person has the thought they offended someone (the obsession) and seeks reassurance from the person they feared offending (compulsions), or they could be seemingly unrelated (e.g. a person steps on a crack in the sidewalk and fears a family member will get into an accident (obsession) and then counts to prevent it from happening (compulsion) (American Psychiatric Association, 2013). This list of OCD symptoms is by no means exhaustive, and any one of the obsessions could be followed by a different type of compulsion. People may present with obsessions and compulsions that are not in the literature. However, the underlying factors involved with different expressions of OCD are similar, which includes the fear of thoughts, uncertainty, doubt, and strong urges to decrease anxiety by doing a compulsion. In addition, all the compulsions (regardless which type) end up maintaining or making the fear stronger, even though they may decrease the anxiety temporarily.
In therapy, we do not want to become too focused on the “expression” of OCD, but rather on learning to break the OCD cycle. The person learns about OCD, and how the symptoms are maintained or made worse. The core fears are identified. The therapist and the individual develop an individualized plan for slowly getting exposed to the triggers while refraining from engaging in the compulsions. This will help challenge the core fears. Through this process the person often learns that the anxiety decreases on its own without engaging in the compulsion. It allows for learning that that the feared outcome either didn’t take place, or that they can live with the uncertainty of the feared consequence. OCD tends to be a chronic condition, but ERP has shown to be an effective treatment for most people who complete the therapy. The length of therapy will vary with each individual, but one could expect therapy to last between 12 to 20 sessions.
Casey Wagner, MSW, LICSW
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA. American Psychiatric Publishing.