AS HUMAN BEINGS, we are complicated thinkers and can be affected by specific influences depending on the situation. We want to be sure that we’re OK, 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, such as, locking doors once before going out in the morning and at night before getting into bed.
When OCD interferes
However, when obsessive-compulsive disorder (OCD) interferes, emotion and conflict tend to get in the way of rational thought. One loses sight of reasonable mind and relies on feelings and guesses instead of facts. It’s because OCD involves obsessions, which are fears of something terrible happening. Compulsions follow the obsessions, which are the behaviours to prevent the terrible thing from happening and reduce anxiety.
For instance, I remember having an obsession about something horrible happening to my family if I didn’t double-check all the doors were locked before heading off to work. No matter how many times I checked, my anxiety would resurface and often reached uncomfortable limits. My uncomfortableness, to me, was evidence that risk was high, so I did the checking compulsion again to minimise the chance of harm occurring, and to feel safe. Without OCD, the intrusive thoughts about danger might have puzzled me a little bit, but not where I couldn’t let them go. Instead, the thoughts stuck like glue, and I found myself caught in the OCD trap. It felt like there was no way out of the spiral.
How insight plays a role
When we have good insight, it allows for a better understanding of different perspectives. For instance, people who don’t have OCD know their feelings are not evidence of facts, which means their thinking style will be less judgmental. Rationally thinking about what might or might not happen and then influencing what we do next helps with decision making and getting on with our day.
For example, if I’d have locked the door once before going to work, it would have shown that I had the insight to grasp that the chance of a burglar breaking in would be minimal. In other words, I would trust that while I was at work, the likelihood of something awful happening at home would be close to zero, helping me to live more comfortably with uncertainty.
When OCD comes into play, however, it clouds insight, meaning the feelings-versus-facts perspective is hard to grasp. For instance, and in contrast to someone who locks their door once, I remember catastrophising, irrationally thinking that the likelihood of something terrible happening was high. Subsequently, the underlying threat that my family was in danger made my anxiety go through the roof. I was on constant alert, and my checking often made me late for work, which added to my anxiety levels being so high. But I could not tolerate uncertainty. My emotional judgement about what might or might not happen had taken over my life.
It can be helpful to identify that stress could be making things worse, too. An extra workload, moving home, problems in a relationship, new baby, and so on, can all add to everyday stressors. Acute stress or burnout can then 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-if scenarios and doubts about our state of mind.
Cognitive behavioural therapy helps to change thinking errors based on emotional reasoning and gives people who have OCD the confidence to live with uncertainty. It sets the foundation for engaging in the systematic resisting of harmful 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 how my anxiety and emotional evaluation had been influencing my decisions. In my subsequent remission, I can lock the doors once now, and then walk away while accepting that certainty can never be guaranteed. Also, to see that should something terrible happen away from OCD, that mostly I would cope.
Medication (SSRIs or tricyclic antidepressants) can be helpful as an adjunct to ERP, especially when symptoms are moderate-severe. Medication alters brain chemistry to reduce symptoms, usually by up to 60%. ERP, on the other hand, actively alters brain chemistry (neuroplasticity).
Generally, people are complicated thinkers, but rationally, most manage risk in terms of probability. For those of us on the OCD spectrum, doubts and what-ifs make living with uncertainty difficult; 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 and sensations mean. Cognitive therapy helps to change unhelpful thoughts, feelings and behaviours, and ERP is the active therapy that can lead to remission or much-reduced symptoms. Finally, medication can often be a helpful adjunct to ERP therapy.
“unshackle is not about jargon or loudspeak. unshackle is not about lofty, unachievable dreams. unshackle is about you. Be it something as intimidating as a mental wellness issue, or something as simple as uncluttering your mind, unshackle is about you, dear reader. Talk to me and I will show you how.”
My colleague, Sunil Punjabi, is a confident therapist and highly recommended for his expert approach in delivering mindful-based ERP with acceptance commitment therapy, the treatment of choice for OCD. He does call and skype and offers a sliding scale. For more details you can contact me here.