Why Obsessions are not True 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.

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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.

So they still desire certainty, is that right?

Yes, doubt versus certainty plays a significant role in OCD. A person’s search for reassurance strengthens the obsession, so reinforcing this concept in therapy is a must.

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 and thus miss the “threat” factor. So it’s vital to help them understand the difference between emotion mind and rational mind.

What is the “threat” factor?

This is where someone perceives their problem as one of threat instead of worry. For example, when someone has a harm obsession, their understanding of the problem is based on an irrational concept. This links to over-importance of thoughts and catastrophising. Subsequently, emotional reasoning further clouds rational thinking and the person tends to question their actual values.

Can you expand on that?

Yes. Someone who has harm OCD (or other disturbing obsession) shows their actual values, which is, paradoxically, 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. 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 a concept that’s difficult to grasp.

How can someone grasp this concept?

One example is known as 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).

How does this experiment work?

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 say contamination fears, one suggestion is for the patient to observe others interacting with each other and noting down the different types of responses that occur in this type of situation, which allows for rational concept. An example of both theories might be:

Theory A: The problem is that I feel anxious when I'm interacting with people; it's like they're all infected with HIV and I'm terrified I will contract this disease even without person-to-person contact. 
Theory B: The problem is that I care very much about interacting with people and the thought of contracting HIV from someone causes me great distress.

As noted, by working on rational concepts for theory B means the threat element (theory A) starts to weaken.

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 “vague” memory because it never existed.

It’s essential, therefore, to work with the patient to locate the pieces of information that are true and 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.

So living with uncertainty is one of the factors for reaching recovery, right?

Yes, this is one of the factors that is involved in the treatment plan for OCD and 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 faulty ideas, 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 grab hold of certainty. Improved insight can help them know that while they want this type of assurance that living with uncertainty is better than feeling under irrational threat forever.

Can obsessions turn into delusions?

Yes, obsessions can turn into delusions and delusions can turn into obsessions. A person’s misconceptions in this instance aren’t to be confused with those seen in psychosis. For example, if insight into an obsession is poor/lacking then this shifts from overvalued idea to delusional belief; a belief in psychosis, however, 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 since practising exposures squeezes the obsession, improving insight.

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 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. Including the 3 A’s into exposures is also helpful since this technique contributes to building distress tolerance in which ERP leads ultimately to remission.

Summary

First, cognitive restructuring helps alter thoughts, feelings and behaviours and improves insight. Subsequently, agreeing to face obsessions (exposures) and resist compulsions (response prevention) shows how this active process eventually weakens obsessions and aids in one’s recovery. When treatment comes to an end, a personal blueprint helps patients maintain their gains. This blueprint details a new set of healthier beliefs together with behavioural/exposure strategies that worked during treatment, and to prevent a full-blown relapse in the future.

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By Carol Edwards © 2018 Updated 2019

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OCD – Why Include Mindfulness into Therapy

Research is always looking at improving patient engagement and to decrease drop-out rates. A pilot study to integrate Mindfulness into ERP (Strauss et al, 2015) showed the drop-out rate was twenty-five percent. It could be said that the reason for this is that people on the OCD spectrum who show poor distress tolerance need the combined approach to help them complete their course of ERP treatment.

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What about those who do ERP successfully, how can Mindfulness help them?

Well, while some do complete their course of exposure response prevention (ERP) therapy successfully, there are others who don’t fully engage with the assigned ERP homework tasks out of the therapy room. This means treatment outcome is poorer than it is for others who do fully engage. Bringing in Mindfulness can be an additional benefit either way.

If ERP effectively desensitises a person from the things they fear, wouldn’t Mindfulness distract away from this goal?

No, because Mindfulness opposed to distraction is that the first represents a state of awareness and so the focus is the accepted attention towards intrusive thoughts in a non-judgmental way. Whereas, distraction is non-acceptance; therefore, avoidance/escape from the intrusive thoughts, which, as compulsions go, only serve to reinforce the problem.

But what about anxiety, how can someone manage this whilst accepting the thoughts?

Mindfulness training is also about accepting feelings and bodily sensations. It means a person remains concentrated on the exposure situation and leans into the anxiety. Therapy teaches them that anxiety rises and falls and eventually reaches a plateau.

So Mindfulness enhances therapy, is that right?

Yes, many take very well to Mindfulness. One reason that it enhances therapy is that a person learns to be non-judgmental about their intrusive thoughts during exposure. The chance of attempting to divert from the intrusive thoughts (by yielding to compulsions) therefore becomes less likely.  In a nutshell, the aim is to Acknowledge unwanted thoughts are there; to Accept the thoughts as intrusive and nothing more; and to then Allow the thoughts to come and go without giving into compulsive responses.  

How does Mindfulness help with emotions such as guilt and shame?

It teaches someone that it’s counterproductive to fall into ruminations about these emotions. Guilt and shame are best seen as intrusive and treated as such. For example, just like an intrusive thought might be about harm and Acknowledging that, Accepting it, and Allowing it to come and go, the same would apply to guilt, shame, disgust etc. This is because the harm obsession is null and void; therefore, guilt and other destructive emotions would be too.

What if guilt is carried over from a real-live event and has become part of the obsession related to that guilt?

Despite past events morphing into an obsession, it’s important to recognise that resulting emotions about the obsession are sensations that make us believe something is true about us, yet are non-factual. In other words, if I were to label myself “disgusting” for having intrusive thoughts about paedophilia, and feeling guilty about that, it would be the result of erroneous beliefs about the obsession, not a past event where I was a victim of child sexual abuse; and where I carried the blame/guilt throughout my childhood. Active listening from a therapist helps to legitimately address and resolve blame/guilt from the real-life event, and then it moves on and concentrates on the process for Mindfulness exposure to treat the obsession.

Does Mindful-based ERP combine well with medication?

Yes, medication helps reduce the symptoms of OCD by changing the brain’s chemistry on a passive level. This helps a person engage in the cognitive side of therapy. The benefit from cognitive change plus the decrease in symptoms from medication further prepares for the active part in therapy, ERP, which ultimately leads to recovery.

How else can Mindfulness encourage people to respond more positively to ERP?

To understand that it provides an opening for full awareness, and to see that they are in charge of their choices. This way, they learn to mindfully influence what happens in any situation; instead of reacting automatically (emotionally). A Mindfulness-based approach to ERP, therefore, helps someone better recognise the urges that would have them give in to compulsions for temporary gain, and to make a choice to resist these for long-term gain, which is recovery (remission) or much-reduced symptoms.

Which book do you recommend?

Everyday Mindfulness for OCD: Tips, Tricks, and Skills for Living Joyfully” by Jon Hershfield, MFT and Shala Nicely, LPC.

Discover how you can stay one step ahead of your OCD. You’ll learn about the world of mindfulness, and how living in the present moment non-judgmentally is so important when you have OCD. You’ll also explore the concept of self-compassion; what it is, what it isn’t how to use it, and why people with OCD benefit from it. Finally, you’ll discover daily games, tips, and tricks for outsmarting your OCD, meditations and mindfulness exercises, and much, much more.

Review

Summary

Exposure response prevention has been practiced for almost half-a-century and remains the most effective therapy for treating OCD. With Mindfulness integrated into the process this offers a solution for improving task engagement (in and out of the therapy room) and offers scope for preventing relapse.

By Carol Edwards 2018 Updated 2019

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