Why Obsessions are not Delusions

The word “delusion” in obsessive-compulsive disorder explains the absence of insight, not fixed belief associated with psychosis. Insight and pathological doubt provide clues about how psychological treatment might work differently for each person on the obsessive-compulsive spectrum and show whether this treatment is likely to be useful or not.

How does a clinician assess insight?

This would usually be taken into account during assessment with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS II). If not, any signs would typically be revealed during treatment. The same goes for pathological doubt.

Insight

First, intrusive thoughts or obsessions can be described as involuntary interruptions that get sandwiched between every-day regular thoughts. While intrusive thoughts interfere, they do not exist outside of a person’s awareness and do not convert to action. People who have good insight into their OCD know this, but have doubts about it. Their search for certainty strengthens the obsession, so reinforcing the concept that all rituals must be resisted, is a must in therapy – these would include reassurance within oneself or from others, checking and ruminating.

Why else is this concept reinforced?

Some patients convince themselves their fear has or will come true, even though the emphasis is that emotional reasoning supports those assumptions. They find it hard to grasp that feelings and guess-work are not factual evidence. Therefore, it’s vital that a therapist helps them understand the difference between emotion mind and rational mind. For example, a person who has a harm obsession (or other disturbing obsession) will tend to catastrophise when they think about their problem on an emotional level; subsequently, they question their actual values and view the problem as one of threat.

Paradoxically, their actual values are that they care deeply about people. The problem is that they cannot get past the barriers that confuse them when their intrusive thoughts “say” otherwise. They feel pinned down by OCD, fearing they are capable of putting thoughts to action, or that the feared thing is more likely to happen, than not. It’s not so simple to eradicate fears despite OCD being a paradoxical disorder. People who have OCD are in conflict, they go over the relentless doubts when trying to understand their thoughts – thoughts that will never be subject to analysis.

How can someone grasp this concept?

One example is the Theory A and Theory B experiment (Salkovskis & Bass, 1997). The person would look at their problem as worrying (theory B) about the thing that bothers them instead of fearing to be under threat (theory A).

First, worry (theory B) is to feel anxious about something unpleasant that may have happened or could happen in the future; and threat (theory A) comes with “warning signals”. A person agrees in therapy to test out theory B by finding workable solutions to overcome their worry, thus removing the threat element. So on the subject of a harming obsession, where a person might fear hurting someone in a public area, one suggestion would be for the patient to frequent public areas, and at a distance, observe others interacting with each other. They would note down the different types of responses that occur in this type of situation. By doing this in graded steps, they get the opportunity to see their problem objectively, which helps decrease the emotional belief surrounding probability or likelihood about the event occurring. The benefit is that this experiment helps increase the rational belief that their fear is over-exaggerated, and as a consequence improves insight.

An example of both theories might be:

Theory A: The problem I feel anxious when I have to walk into busy areas, because I think I will hurt someone accidentally.

Evidence: My anxiety is a clue that my fear could happen.

What do I need to do if theory A is true?

Stay at home, avoid the situation. (This feeds the problem)

Theory B: The problem is worry that I have to walk into busy areas, because I’m hypervigilant about other people’s safety.

Evidence: I feel responsible for others’ safety.

What do I need to do if theory B is true?

To understand that just because I feel responsible for others’ safety doesn’t mean I have to take extreme caution. Feelings are not facts, and so I will learn how to manage my worry, and work on strategies to help me be less watchful of other people’s safety when I go into busy areas.

Is it true that false memory confuses insight?

Well, let’s say memory tends to play tricks for a person who has OCD. When this happens, they will ruminate at length, searching their minds for abstract recollections. However, while they might remember an existing memory, even when some of that memory is lost, they will never recall a “false” memory, because it never existed.

It’s essential, therefore, to work with the person to locate the pieces of information that are true, and then filtering out the rest. As an example, let’s go back to the person who has a harm obsession. Let’s assume they were in the same area at a time when someone was hurt in an accident. Later, they might “add” to the memory a non-existent one in which they fear they might have been the one who harmed that same person. They have this fear because they were wearing a blue jacket similar to the person who caused the accident. Learning to live with uncertainty would be reinforced in therapy, and this works better for people who have good insight.

Can a person’s insight improve?

Sometimes. Cognitive restructuring can help a person alter thinking errors linked to entrenched beliefs, although some often lose sight of their new healthier beliefs, because their need for certainty overrides this. Pathological doubt clouds insight and drives behaviours to prove obsessions right or wrong, which makes exposure response prevention (ERP) more of a challenge when the person cannot determine the outcome one way or the other. Improved insight can help them know that while they want this type of assurance, that living with uncertainty is the better option. They start to see that feeling under irrational threat forever keeps the OCD going in a circle.

Can obsessions turn into delusions?

Yes, obsessions can turn into delusions and delusions can turn into obsessions. A person’s misconceptions, however, aren’t to be confused with those seen in psychosis. For example, if insight into an obsession is poor or absent, then this shifts from overvalued idea (poor) to delusional belief (absent). A belief in psychosis, on the other hand, is fixed and does not follow the regular OCD cycle.

For delusion in OCD, insight can be worked on with cognitive restructuring of thoughts to change the pattern or significance of those thoughts. When the delusion turns into an obsession, it shows that cognitive restructuring has illuminated insight. Also, exposure response prevention squeezes the obsession, improving insight even more.

A new perspective, plus a reduction in symptoms, allows the person to comprehend the significance of false versus real events concerning the obsession, and to see that all real events are separate from it. For example, it’s true that the person was wearing a blue jacket at the scene involving injury, but this does not make valid the perception, ‘What if I was the one who hurt the injured person?’

What else helps a person reach recovery?

Mindfulness techniques and ACT (acceptance commitment therapy) are helpful because these help someone do what I call the 3 A’s. These are to Acknowledge, Accept and Allow intrusive thoughts to come and go in the present without passing judgement.

Summary

Cognitive restructuring helps alter thoughts, feelings and behaviours, and improves insight. Subsequently, agreeing to face obsessions (exposures) and resisting compulsions (response prevention) shows how this active process eventually weakens obsessions, further increasing rational perception.

By Carol Edwards © 2018 Updated 2019

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