I’m afraid I will act on my intrusive harming thoughts? Is it true that this does not happen? And are compulsions the opposite of impulses in terms of people acting or not acting on their thoughts?

First, my thoughts on whether compulsions are the opposite of impulses are that in OCD a compulsion is to “prevent” harm; yet, an impulse outside of OCD can potentially cause harm. For example, when an OCD thought occurs and a person feels they are urged to act on that intrusive thought (e.g., harming oneself or someone else) it can seem a bit like Russian roulette. However, when a person who has an impulse control disorder is faced with an urge to harm oneself or someone else, this is like Russian roulette.

How do you mean?

Well, Russian roulette is a game of high risk. Each player, in turn, and using a revolver containing one bullet, spins the cylinder of the revolver, points the muzzle at the head, and pulls the trigger. The question is which player will get the bullet?

In likening the risk with OCD, let’s say OCD says to Mr Johnson (who has suicidal intrusive thoughts with magical thinking, and is trying to work), “Take the gun from your drawer and shoot yourself, or your family will die.” This leaves Mr Johnson in a “fight” or “flight” situation. Will he be the “player” who gets the bullet – that is, by fleeing the scene (avoidance ritual) to “prevent” perceived harm and thus bringing his anxiety down momentarily? Or will OCD be the “player” who gets the bullet?

Where is this leading, and how would OCD get the bullet? 

What would happen is that should Mr Johnson acknowledge, accept and allow the thoughts to pass instead of escaping the obsessional scene then OCD would get the bullet. But because OCD is an anxiety disorder, Mr Johnson becomes so panicked that the urge to flee the “dangerous” situation overwhelms him. By following through with the escape plan, he gains anxiety relief; however, this momentary gain means OCD “wins the game”.

In other words, the avoidance/escape ritual is a negative response which strengthens Mr Johnson’s fear-related obsession, and so OCD continues to master control.  Other compulsive behaviours occur for Mr Johnson too, such as checking, praying and seeking reassurance that no harm has or will occur. These compulsions serve only to compound the problem; by giving into them Mr Johnson never gets the chance to prove that his fear isn’t evidence that something bad will occur.

Now despite the fact that OCD thoughts are paradoxical to Mr Johnson’s true wishes and desires (it’s his obsession that tells him he should kill himself to protect his family, not him) this unfortunately is of little use to him. Much of this is due to doubts and “what-ifs?” plus erroneous beliefs seen in OCD. Subsequently, he continues to yield to compulsions “just in case”. What he doesn’t trust yet is that obsessions do not convert to action, hence there being no need for compulsions to prevent a catastrophe.

But is there any further proof that he won’t act on his thoughts?

Yes, because while biologically generated intrusive thoughts make Mr Johnson feel a  pressure to respond, this pressure is fear, not a true call to action. One theory of proof that intrusive thoughts do not convert to action is for Mr Johnson to consider how the perception of body movements (kinaesthesia) work. This involves being able to detect changes in body position and movements without relying on information from the five senses. Even though this confirms that any obsessional urge will be automatically restricted it’s more important to note that obsessions are invalid pieces of information. This means while intrusive thoughts fire into the consciousness they are none-the-less baseless, and so thoughts without foundation in factual evidence will never materialise.

But if the urges are so strong, how do these differ from impulsive urges outside of OCD?

As far as impulses go, and when these are OCD-related, the urge can feel very strong. This is why people with OCD yield to the corresponding compulsive responses to “prevent” perceived harm, just like Mr Johnson does. Still, when referring back to kinaesthesia coupled with not only contradictory but also unverified information coming into the mind proves again that compulsive responses are not required.

How does kinaesthesia differ from obsessional urges seen in OCD and those seen in impulse control disorder (ICD)?

An impulse seen in an ICD is challenging and dangerous in that the impulsive action could in all likelihood occur; yet, an impulsive urge seen in OCD is an obsessional fear.  In other words a person feels threatened that their urges will come true and because of that the repeated compulsions to ward off perceived danger continue. As the term shows, ICDs are a class of psychiatric disorders characterised by impulsivity, not obsessions. For example, one person with an ICD had an ongoing impulse to run across roads and reach the pavement before oncoming cars reached her. In contrast another person had an obsession to do a similar thing yet avoided going near roads. This clarifies the difference between harmful impulses seen in an ICD and avoidance of harm obsessions seen in OCD. The same goes for someone suffering from kleptomania, the impulse to steal differs for a person who has an obsessional urge to steal. Further, people who cannot resist the impulse to expose themselves in public differ from another person who has an obsessional urge to expose themselves, and so on.

So ultimately, what can Mr Johnson do to make sure OCD gets the bullet instead of him?

By resisting compulsions in graduated steps Mr Johnson will begin starving the obsession and OCD will eventually get the final bullet. O.C.D. – An Effective Strategy for Resisting Compulsions

Summary

It can be determined that impulsive urges within the obsessive-compulsive category are not acted upon; yet compulsions to ward off perceived danger and to relieve anxiety are acted upon, but are not required. In addition, there appears to be no problems in the process that describes kinaesthesia in the way there is in those who have an ICD. While no theory need be explained why obsessions cannot possibly come about it does provide an avenue of thought for those who desire some level of proof. In sum, an obsession is just that which means intrusive thoughts never come true. Impulses in the ICD group on the other hand can occur and kinaesthesia impairment is likely one of the causes.

© Carol Edwards 2017

Impulse Control Disorders: Updated Review of Clinical Characteristics and Pharmacological Management

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