A ritual seen in obsessive compulsive disorder is goal-directed but has no rational justification. For example, daily activities such as washing oneself once has an appropriate end-point – that is, to feel clean. However, going to excessive lengths in washing oneself to feel cleansed will never be satisfied, meaning the end-point can never be reached. Similarly, checking once that the doors and windows are closed before going to bed has a purpose, which is that the house has been made secure. Yet, checking repeatedly to “prevent” harm only serves to relieve anxiety in the short term, hence the repetition; thus, the end-point will never be arrived at.
Fear induces chemicals such as adrenaline and the stress hormone cortisol to be released into the blood stream. When this occurs, it triggers a fight-or-flight response that causes us to react to the situation appropriately. However, when this happens within the concept of OCD, the reaction is inappropriate. This is because the person hasn’t learned yet that the “threat” element is as invalid as the intrusive thought itself, meaning because an unwanted thought came into one’s consciousness, it doesn’t mean that the thought will materialise.
All obsessions are fear related. It’s this fear that drives corresponding rituals to “correct” the problem even though in the long term they are of no use. Obsessions might relate to harm, sexual, symmetry, cleanliness, somatic, moral or other; and resultant behaviours include reassurance, double checking, confessing, cleansing, praying, and so on.
The uncertainty of what has, is or will occur creates a resistance to rational persuasion, hence re-occurring doubts and repeated responses to remedy the problem, albeit unsuccessfully. Basically, no amount of checking, reassurance or other repeated behaviour ever takes away that grain of doubt. This is why living with uncertainty is encouraged because certainty can never be guaranteed.
COGNITIVE THERAPY WITH EXPOSURE RESPONSE PREVENTION
The way to break the circle of OCD is with cognitive behavioural therapy (CBT) with exposure response prevention (ERP). The first (CBT) helps to correct errors in thinking. When these change so do feelings; thus, behavioual outcomes are generally more favourable. Likewise when an unhelpful behaviour changes, healthier thoughts and feelings follow. You can see here how thoughts, feelings and behaviours interact, so in sum, when you change a thought about something, it automatically changes how you feel and behave; or if you change a behaviour, the same applies with the way you think and feel.
Thinking errors are when you assume your feelings are evidence of a fact – e.g., “I feel anxious, therefore the situation must be dangerous”; or “I feel guilty, so I must have done something wrong”; or “I felt a groinal response, therefore I must be gay, a paedophile (or other)”. These thinking errors are linked to faulty beliefs such as catastrophising and overimportance of thoughts. By encouraging the resistance of pursuing purposeless goals, the second (ERP) is able to help OCD sufferers build distress tolerance and eventual habituation. In other words a person agrees to face their fears (obsessions) in graded steps with the purpose of resisting giving into all corresponding compulsions for the duration of their exposure time and where the main goal is to starve the obsession and thus experience desenstisation to their fear-related obsession. This is why ERP is the gold standard treatment intervention known to actively alter brain chemistry to reduce OCD symptoms.
Whilst medication is not an active replacement for working on rational goal-directed behaviours it is often required in moderate-severe cases to allow for cognitive improvement, and in which a person is then more able to become actively involved in ERP. Selective Serotonin Reuptake Inhibitors (SSRIs) such as Sertraline (Zoloft) are the usual prescribed medications for OCD and are known to passively alter brain chemistry to reduce obsessions, usually by up to 60%. Just to note: an old class of tricyclic antidepressants – commonly Clomipramine (Anafranil) which works well for OCD – might be prescribed if a person cannot take to a SSRI. If a SSRI isn’t working as well as it can do, an atypical anti-psychotic such as Aripiprazole, sold under the brand name Abilify, might be added to boost the effectiveness of the SSRI.
Now have a go at answering the questions below to reinforce the learning objectives.
- A certain reaction drives a person to pursue goal-directed behaviours that have no rational justification. What is this reaction?
- Within the concept of OCD, explain why a fear-related reaction is inappropriate?
- What makes a person resistant to rational persuasion?
- If no amount of engaging in rituals ever takes away doubt, what is encouraged instead?
- Thinking errors are when you assume your feelings are evidence of a fact – e.g., “I feel anxious, therefore the situation must be dangerous.” True/False?
- What are thinking errors are linked to?
- Briefly describe your understanding of how thoughts, feelings and behaviours interact?
- Why is living with uncertainty encouraged?
- How does ERP actively reduce OCD symptoms?
- Which treatment intervention is able to passively alter brain chemistry to reduce obsessions by up to 60%?
- How can medication help someone with moderate-severe symptoms become more actively involved in ERP?
- Write a short summary of the main learning objective described in the article.
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