Pure ‘O’ OCD and Psychotherapy
Dr Christian Jonathan Haverkampf, M.D.
Abstract – Obsessive-Compulsive Disorder (OCD) is a condition in which people feel the need to check things repeatedly, perform certain routines repeatedly (‘rituals’), or have certain thoughts repeatedly. People are unable to control either their thoughts or their activities for any longer periods of time. Suppressing the behavior or thoughts often causes intense feelings of anxiety, tension, nervousness and fear. OCD is quite common, and it is mostly treated with a combination of psychotherapy and medication.
There is some discussion as to whether categorizations of OCD into heterogeneous forms, including a pure obsessive form, make sense. However, there are common themes and mechanisms underlying any form of OCD.
Keywords: OCD, communication, psychotherapy, psychiatry
The rituals usually have the function to reduce anxiety and fears of serious threats to the individual or someone else. In the beginning, the self-soothing can work for a short time. In the long run, however, they tend to lose their effectiveness and may have to be increased in frequency or intensity. Suppressing them leads to even greater anxiety, before it then decreases again and disappears.
There is some discussion as to whether categorizations of OCD into heterogeneous forms, including a pure obsessive form, make sense. However, there are common themes and mechanisms underlying any form of OCD.
The rituals can be checking whether a door is closed multiple times, walking only on every second tile or washing one’s hands for an extended length of time. Thoughts can include counting or doing things in certain quantities. Intrusive thoughts can also be about harming another person, which seems alien to one’s personality. Some might still have obvious meaning, like someone who moved a lot in childhood checking the door compulsively, while other urges, such as counting all the lighter colored tiles on the wall, may not seem to make much sense.
Intrusive repetitive thoughts may use different mechanisms and pathways. They do not reduce anxiety, but can heighten it. However, just like with compulsive behavior, suppressing obsessive thoughts often increases the feeling of anxiety.
Reassurance seeking is an important element of OCD. Excessive reassurance-seeking (ERS) is a common problem among both obsessive-compulsive and depressed populations. However, the content and cognitive processes involved in ERS may differ in these populations according to the unique cognitive and behavioral characteristics demonstrated by each group.
Patients suffering from OCD seem more worried about perceived general threats, such as a catastrophic fire or a severe illness, while depressed patients may be more worried about social threats, such as abandonment. However, there may be significant overlap in the individual case.
ERS is a common problem in clinically anxious populations, particularly among individuals diagnosed with Obsessive-Compulsive Disorder (OCD), Generalized Anxiety Disorder (GAD), and/or Hypochondriasis / health anxiety (Clark, 2004; Dugas & Robichaud, 2006; Freeston & Ladouceur, 1997; Hadjistavropoulos, Craig, & Hadjistavropoulos, 1998; Morillo, Belloch, & García-Soriano, 2007; Salkovskis & Warwick, 1986). Within the context of these disorders, ERS may be more broadly defined as the repeated solicitation of safety-related information from others about a threatening object, situation or interpersonal characteristic, despite having already received this information. Although there is a paucity of research examining the specific factors that promote ERS in anxiety disorders, evidence suggests that it is among the most common strategies used by OCD patients to try to diminish their obsessional thoughts and images (Freeston & Ladouceur, 1997), and that individuals diagnosed with OCD are significantly more likely than clinically depressed, nonobsessional anxious, and non-clinical individuals to seek reassurance regarding negative intrusive thoughts (Morillo et al., 2007).
It makes a significant difference whether one feels responsible for any negative events. In the beginning, therapy can already be helpful if the therapist tells the patient to reduce compulsive behaviors.
Results revealed that OCD patients used punishment, worry, reappraisal, and social control more often than non-patients. Conversely, distraction was used more often by non-patients than OCDs. Interestingly, punishment was the strongest discriminator of OCDs and non-patients mostly because of the low frequency of its use by non-patients.
In OCD there is the fear that not carrying out a thought or engaging in a behavior has an influence on things happening in the real world. This can be a remainder of different ways of processing information from childhood where the reference point for efficacy and influence is still much more focused on oneself, the belief that simple behaviors and thoughts can bring about a change in the world and how it interacts with us. (Haverkampf, 2017a) This may be linked to feelings of helplessness in the child or adolescent. It could also be a misattribution of sources in the present, in which thoughts are interpreted like real objects with real consequences. (Haverkampf, 2014) As we will see below, reducing feelings of helplessness and establishing better boundaries between thoughts and the outside world are important elements in reducing magical thinking.
Thought-action fusion is when one believes that simply thinking about an action is equivalent to actually carrying out that action. An obsessive focus on intrusive thoughts can make thoughts seem more real and more relevant. However, one element of this greater sense of reality may be in the lack of distinction between outside and inside events and the effect each of them can have on the individual.
One reason why making thoughts seem more real could convey an advantage in normal circumstances is that we need to feel strongly about something to have the motivation and initiative to make change in the world. If a future one dreams up seems very unreal, it may be less motivating to implement action and changes to get there. Obsessive thoughts, however, do not seem voluntary or directed towards a goal that agrees with the own needs, values and aspiration. They are emotions and feelings which are expressed in thoughts, whose content then triggers new feelings and emotions. All this happens far away from the real world, but they can effect how one interacts with oneself and the world. The obsessive thought about driving off the Golden Gate Bridge can lead to avoidant behavior, such as using a different route, if possible, or engaging in compulsive behaviors to reduce the anxiety of the intrusive thought.
It is true that thoughts can change the world in very real ways. However, in OCD it is as if communicating them and acting on them is not necessary to bring about a change in the world. The communication process thus seems to be short circuited.
The internal and external communication difficulties as causes of thoughts and feelings that can lead to the fear of harming self or others via overwhelming impulse or by mistake or religious obsessions can also lead to poorer insight, more perceptual distortions and magical thinking in general, which has also been demonstrated empirically.
Reality is that what exists as opposed to what is imagined. One may also say that reality is what is perceived but not imagined, and vice versa. In the brain, one way to hold the information apart is a mechanism that keeps track of whether information flows from higher level areas to lower ones (imagination) or from lower to higher ones (sensory inputs from the outside world). Thus, even though the information may be about the same content it has to be different to account for the fact that the source is the imagination for one, and a sensory input from the real world for the other. One attribute that makes it different is the direction which it travels by. (Haverkampf, 2018)
Reality is a result of communication, both internal and external. Changing the perception of reality can also change the likelihood of magical thinking/ideation and thought action fusion as the separation between mental acts and acts in the real world blurs. This is not necessarily a sign of psychosis but the separation between the internal and external world changes.
All the behaviors and thoughts have in common is that they provide an option to reduce anxiety by focusing on behavior and thoughts that seem to have a clearly defined system, no matter how illogical. But they often are not very effective. Anxiety can actually increase if one gets caught in these thought and rituals. But why are they still used? I believe they are a feeble attempt to calm oneself when there is no one else available to do so. What causes the anxiety is an intolerable probability of negative emotions in the future. Rather than experiencing the negative emotions in the future I experience them now. If I am afraid of a relationship breakup, I experience now anxiety about the potential future emotions from the breakup. The less certain I feel about the future, the more I do things that seem certain to compensate for the uncertainty and feel more certain. Of course, this a subconscious process, but it is important to see that the brain engages in self-regulation. To get out of this one either needs to see the world as more certain or the uncertainty as less of a burden. Better communication with the world takes care of the first part, a better for oneself of the second.
Anxiety is acutely felt once the repetitive behaviors or thoughts are suppressed. This anxiety comprises the sense of tension, fear of impending doom and other unpleasant emotions. It increases when existing mental resources are already low due to stressful life experiences, internal conflicts or interpersonal difficulties. Relationship or workplace problems, the pressure of not meeting one’s expectations or a loss of direction in life may all help trigger OCD.
OCD patients usually differ from those with anxiety on beliefs about the importance and control of thoughts, but not on beliefs about threat estimation and inflated responsibility. It is quite often observable in clinical practice that approaches that help to lower the experienced anxiety levels often also reduce the pressure to engage in obsessive thoughts and compulsive behaviors. (Haverkampf, 2017b, 2017c)
Like many other psychiatric conditions, OCD begins at the boundary of normal behavior and thought, the little everyday rituals and the occasional nagging thought, that are hard to suppress but do not interfere with one’s life and happiness. At the other end of the spectrum is the house bound, or even bed ridden individual who can no longer take part in daily life. In the latter case, getting dressed can take hours and such mundane things as washing one’s hands get caught up in endless loops of repetitive or highly ritualized steps. The obsessive element of OCD refers to repetitive thoughts, like counting things, while the compulsive element refers to repetitive behavior, such as walking upstairs by making sure to only tread on each step with the left foot first. In most instances, OCD manifests with both obsessive thoughts and compulsive behaviors. Suppressing these behaviors or thoughts can cause feeling of uneasiness, anxieties and fears of dramatic events.
Studies of children and adolescents with OCD have reported both similarities and differences with the adult form of the disorder, which may point to early-onset OCD as a distinct subtype of OCD. Studies indicate that the phenotypic differences found between the early- and late-onset groups are not secondary to a developmental phase or restricted to childhood. These findings also support the view that age at symptom onset is likely to be a clinically important factor in subgrouping patients with OCD.
The early-onset group, when compared to the late-onset one, was characterized by significantly higher frequencies of tic-like compulsions, sensory phenomena preceding their repetitive behaviors, higher probability of comorbid tic disorders or Tourette’s disorder, and a poorer short-term treatment response to medication. The early-onset group may have an earlier onset of compulsions compared to obsessions, which is different from the adult onset. It may also have a higher mean number of comorbid diagnoses, and higher frequencies of repeating compulsions and hoarding obsessions and compulsions.
There may also be an important overlap between the early-onset group and the “tic-like” OCD subtype. Although presence of hoarding, comorbid tic disorder diagnosis, and longer illness duration have been associated with a poor treatment response to clomipramine or an SSRI, the age at onset may be the most powerful variable associated with a poor treatment response to medication.
The therapy of OCD can be supported by antidepressants, mainly in the form of serotonin reuptake inhibitors or older tricyclics. But nothing has quite the lasting effect of psychotherapy. The reason is that OCD appears to have a biological component, but that the psychological and social aspects play a large role in triggering and maintaining it. There is probably a predisposition for OCD and some individuals are more likely to develop OCD in stressful situations or after negative life events. Others who have a different predisposition may develop some other condition, such as outright anxiety, or self-medicate with alcohol or drugs in the face of psychological pressure. Sometimes there may not be an apparent trigger of the condition, but quite often there is.
Many techniques can help in confronting OCD, including mindfulness and meditation, but nothing quite helps as much as learning healthier interaction patterns with oneself and others and clarifying one’s values, needs and aspirations. An environment that is predictable yet stimulating has a positive effect on OCD, but it often needs to be created from scratch. The experience of stable relationships helps, while a loss of faith in the predictability of human interactions and helplessness and loneliness can make it worse. Babies learn to feel safe in the world through their interactions with their primary caregivers, children through their interactions in and outside of school, adolescents through social and romantic relationships, and adults in a myriad of business, academic, athletic and romantic relationships. If I have difficulties in communicating my values, needs and aspirations to my environment, the world is more uncertain and I will have more stress, which leads to a greater likelihood of stress, anxieties, panic attacks, OCD, burnout and a host of other psychological and medical conditions in the long run. Important is the act of communication, which can also be ‘virtual’, one reason why keeping a journal or writing down one’s thoughts has been helpful to many people with anxieties and OCD. The act of communication helps to define and live one’s values and aspirations, which give the individual a sense of stability.
Learning to communicate and interact with others is a lifelong learning process, and it also reflects on and determines how we think about ourselves. If one’s communication patterns are not helpful, existential anxieties can ensue, because our sense of self and our social existence is linked to how we experience our relationships with others. Do we address what we want? Do we say ‘No’ to the things we do not want? Even a monk who meditates months on end needs to learn to communicate with himself to find tranquility and with others to survive. Our health, mental and otherwise, depends on how we shape our interactions with the world, as do any achievements in the arts, sciences and business and in relationships.
To treat OCD means predominantly to treat the anxiety underneath it by focusing on the emotions that cause it, such as remnants of fearful or hurtful life experiences. The key for the therapist is to build a working relationship the client that helps lower these anxieties while facilitating the therapeutic work. This requires paying attention to the interaction patterns clients use and then reflecting on it together with them.
Reflecting on the thoughts and daily life which are associated with OCD symptoms should foster a greater openness to try out new perspectives and reach new insights. Various issues from the presence and the past may come up which need to be interpreted in light of the emotions they evoke. Issues are especially important when they change how the individual communicates with the world. If you have nightmares about spiders, the spiders in themselves may not be relevant in themselves. You could also dream about monsters or your boss with the same emotional reaction. Only if the spiders change how you see yourself or others are they relevant in a dream and have an influence of how you interact with yourself and others. In OCD, the repetitive behaviors and thoughts are only relevant because there are thoughts and emotions underneath them, which have not yet fully been communicated.
Breaking down the meaning in the rituals needs to be approached carefully yet thoroughly. The rituals usually give clues of the thoughts, emotions and subjective experiences that help maintain them. Reflecting on why it may be difficult to communicate the underlying dynamics can be central in resolving the OCD symptoms. Rape victims, for example, might feel terrible shame in talking about their feelings and this maintains the rituals as a form of incomplete communication. Breaking down the shame into its components usually makes it disappear along with the OCD symptoms. Usually this does not even require addressing the traumatic event itself, which may just cause fear and resistance. This does not mean integrating a rape as ‘normal’ into one’s experiences, but removing the negative effect it has on one’s life and relationships.
Identifying one’s value, needs and aspiration has another important aspect in dealing with a number of psychiatric conditions. As the individual recognizes them as largely constant through the years, they can induce feelings of safety and security. They have a significant influence on our life, but are highly predictable if one spends the time on identifying them. Insight about them can even be gained when reflecting on the specific manifestations of the OCD symptoms, especially when they are suppressed. After all, these symptoms are maintained by powerful emotions which must be attached to something that is highly relevant to the person. Treating any kind of psychological symptoms is an opportunity for greater insight into oneself.
The fears and anxieties in OCD can lead to ambivalence and resistance towards therapy. An empathic therapist offering sufficient space for reflection and emotional expressiveness helps the client understand that there is nothing to be afraid of. The anxieties underlying OCD are really psychological tensions misinterpreted as fears. They can persist as fears as long as they are not shared and communicated. Psychological tensions can arise from many sources. Maybe at some point in life we really have been fearful, but after the feared situation disappeared, only the tension remained, which then persists and can then lead to the OCD symptoms. Interestingly, once this tension becomes a topic in therapy it may increase at first as it becomes conscious but then tends to vanish as it is seen as only a symptom of an underlying conflict or dynamic that is or relevance to the individual’s values, needs and aspirations.
Psychological tensions may have multiple explanations. They may be related to past experiences involving people important to us, such as primary care-givers, real or imagined love interests and so forth. It does not matter so much whether a relationship was real or imagined because the subconscious of our brain is not so good in making this distinction anyhow. Revisiting past communication patterns, including our reactions in stressful situations and events, helps us identify how we interact with others in the present. It is also helpful to acknowledge one’s success in putting obsessive behavior or compulsive thoughts to rest.
Obsessive thoughts and compulsive behavior can be put in categories, which already lowers their incidence. Chunking them in smaller units helps make feelings of anxiety and fear more manageable. The next step is to observe what happens when a ritual is not performed, whether it is washing one’s hands or the compulsive thought to count all even numbers squared up to 88. Suppressing these rituals may cause anxiety or fear that something specific is going to happen. Interestingly, the concrete fears are often easier forgotten than the rituals, because the former are only placeholders for other uncommunicated fears on a deeper level. One reason for maintaining the rituals is to avoid feeling guilty for not carrying out the ritual and causing a catastrophic event, but in this case, it is the guilt and or any other underlying issues that need to be dealt with. Then the rituals often stop.
Rituals only have meaning to the affected individual, which is one fundamental thing to understand about OCD. Only if we develop an understanding for what sits below them is it possible to communicate them. This is one goal in therapy. The emotions below the rituals want to be communicated and this requires translating them into what they really mean, the emotions underneath them that need to be talked about and shown in the right context of an individual’s life experiences. Underneath the ritual of washing of one’s hands can be the fear of an unfulfilled need or the remnant of an emotional reaction, which can be discovered and communicated in the safety of a psychotherapy session. By verbalizing and communicating experiences associated with the emotions, they can be reintegrated into one’s personal history, which makes the world subjectively a more predictable place.
Trust and confidence in oneself and others are often central issues in OCD, since we are often dealing with feared emotions underneath the compulsions and obsessions. The rituals can have a connection with negative life events, but they do not need to. For example, a rape victim may start taking very long showers with repeated ‘cleansing’ in a ritualistic fashion, that can lead to skin and health problems. However, there is probably a biological predisposition for OCD and the symptoms may be seen as a way to deal with unpleasant emotions.
Accepting oneself means looking at how it feels to be oneself, which can require overcoming fears and distracting emotions and thoughts. The path leading there requires finding out about the values, needs and aspirations one has, which can surface in one’s dreams, preferences, accomplishments and interactions with other people. Insight into them helps build confidence and trust in oneself and others, two important antidotes to OCD.
Obsessive-Compulsive Disorder (OCD) is a condition that illustrates nicely how the brain tries to deal with problems in its own way by recreating the real world in a way that makes unpleasant emotions manageable. All organisms try to avoid unpleasant situations and attract pleasant ones. However, humans have a sense of the past and a sense of the future, which is responsible for the great creative accomplishments we are capable of, but also gives rise to psychiatric conditions. The more one is aware of one’s basic values, interests and aspirations, the more stable the future becomes, which in turn reduces anxiety and the urge underlying many compulsive behaviors and obsessive thoughts.
Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He also has advanced degrees in management and law. The author can be reached by email at jo****************@gm***.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.
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