AS HUMAN BEINGS, we are complex in our thinking and can be affected by certain influences depending on the situation. We want to be sure that we’re okay, that our families are safe, even when that comes with some uncertainty. For most of us, this is fine because naturally, we know certainty cannot be guaranteed. We live our lives accepting probability, and we take appropriate care to minimise risk (e.g., locking doors once before going out in the morning and at night before getting into bed).
However, when OCD interferes, emotion and conflict tend to get in the way of rational thought. For instance, I remember having intrusive thoughts about something bad happening to my family if I didn’t double-check all the doors and windows were locked. No matter how many times I checked the doors, my anxiety would resurface and often reach uncomfortable limits. I saw this as evidence that risk was high; so I did the compulsion one more time to minimise the chance of harm, and to feel safe. Without OCD, I might have initially thought “how strange” but then let the thoughts go without thinking any more about it.
How insight plays a role
When we have good insight, it allows for a better understanding of different perspectives. For instance, if we believe our feelings are not evidence of facts, then our thinking style will be less judgmental. Rationally thinking about what might or might not happen and then influencing what we do next helps with sound decision making; for example, Mr X locked the door, once; therefore, he trusts that while he’s at work, the chance of a burglar breaking in is minimal. When OCD comes into play, however, it clouds insight, meaning the “feelings-versus-facts perspective” is hard to grasp. For example, and in contrast to Mr X, I remember catastrophising which not only made my anxiety worse, it also had me believing there was some underlying “threat”. I was on constant alert, repeatedly checking the doors were locked to ward off perceived danger.
It can be helpful to identify that stress could be making things worse. For example, an extra workload, moving home, problems in a relationship, new baby, and so on, can all add to common every-day stressors. However, acute stress or burnout can cause strange sensations (such as depersonalisation) and erroneously have us think that our OCD thoughts and feelings are inconsistent with the regular OCD cycle. Even still, we’re left with the choice to stand back and put in some rational perspective; or continue to make things worse with what-ifs and doubts about our state of mind.
Cognitive behavioural therapy helps to change thinking errors based on emotional reasoning and gives us the confidence to live with doubts and uncertainty. It sets the foundation for engaging in the systematic resisting of negative reinforcing compulsions. Exposure-response prevention (ERP) is the gold standard evidence-based treatment for this and leads to remission or much-reduced symptoms. One of my exposures was leaving the door unlocked and living with risk; it helped me see that my anxiety and emotional evaluation influenced my decisions before remission. I lock the doors once now, and then walk away, trusting that I’m able to get through a day/night knowing that, while certainty can never be guaranteed, the risk of harm is low.
Medication (SSRIs or tricyclic antidepressants) can be helpful as an adjunct to ERP, especially when symptoms are moderate-severe. Medication passively alters brain chemistry to reduce symptoms, usually by up to 60%. ERP, on the other hand, actively alters brain chemistry (neuroplasticity).
Generally, we are complicated thinkers, but rationally, we manage risk in terms of probability. For those of us on the OCD spectrum, however, the symptoms interfere by introducing doubts and what-ifs; as a consequence, an emotional evaluation interferes with our rational perspective. Insight helps us clarify the difference between feelings versus facts; yet, extra stress can cause us to feel confused about what our thoughts/sensations mean. Cognitive therapy can help with this, and ERP is the tried and tested therapy towards remission. Finally, medication is a helpful adjunct for symptom reduction.
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Copyright © Carol Edwards 2018 Updated 2019