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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What to do when a Phobia Becomes Obsessive

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First, a phobia usually involves having a fear of spiders, dogs, fire, open or closed spaces, heights, animals, blood, or something else. People are affected usually only when faced with their specific phobia; yet, can generally switch off when their fear is out of sight.

Specific Phobia

A specific phobia is persistent and intense. There is a compelling need to flee or avoid the feared object, substance or situation. These are factors that are determined before the symptoms are classified a phobia. Also, confirming that the person’s fear is seen as irrational and not reasonable in the given situation.

Obsession

In comparison, people who have obsessions are usually never free from their fears, even though these don’t legitimately exist. For example, having a fear of harm coming to a loved one if certain items are not symmetrical, is an obsession. Subsequently, the corresponding ritual to “prevent” harm is to align the objects repeatedly. It’s these rituals that strengthen the obsession.

Obsessive Phobia

There is another factor to consider, which comes from Isaac Mark’s expression “obsessive phobia” which is not, as he puts it, ‘a direct fear of a given object or situation, but rather of the results which are imagined to arise from it’. While there is a distinction between a standard phobia and an obsession, an overlap can be noticed when a person shows signs of one and the other.

So let’s say a person fears spiders but doesn’t think about them when they are out of sight – this would indicate the norm for a standard phobia. For instance, obsessive-compulsive symptoms seen in a person who has OCD is non-existent in the person who has a phobia. However, when someone who fears spiders repeatedly locks all windows and covers door gaps to avoid spiders getting into their home, the diagnosis might be better suited as “obsessive phobia”. This is because obsessional behaviour is being used to counter the feared thing (Issac Mark). I, (Carol Edwards), have struggled with an obsessive-phobia; later, I’ll explain how I overcame this.

Another example is of a man who has a fear of high-rise buildings. Many are visible on his way to work. This man doesn’t think of tall buildings when they are not in sight. But when he walks a different route to work every morning, where the areas are flat, he is noticeably using an avoidance ritual.

Treatment

In the same way cognitive behavioural therapy (CBT) and exposure response prevention (ERP) are both used to help a person reduce symptoms seen in OCD, the same methods are used to help people overcome phobias and also obsessive-phobias. Medication (SSRIs) and Mindfulness are also often integrated into the person’s treatment plan.

The cognitive side of therapy helps change the perception about feared things, and exposure-response prevention means a person systematically resists giving into compulsions. For example, in graduated steps, the person who has an obsessive-compulsive fear of high-rise buildings would agree to walk by areas where there are tall buildings. First with just one or two, and to tolerate associated anxiety until it reduced naturally, and before going on to the next step, which might be to stand by the buildings; next, to go inside the premises, and so on. The main goal would be to climb the steps of the buildings or to ride up in the elevator with much-reduced anxiety.

Overcoming my obsessive-phobia of spiders

TRIGGER WARNING: I dealt with my obsessive-phobia of spiders by initially agreeing not to cover door gaps and to bear with my anxiety until it came down. When my anxiety reduced to 30% on the distress scale overall, I was ready to tackle my next fear on my list, which was agreeing to look at small spiders, then to hold them; next, I looked at bigger spiders, then I let one crawl on me. Finally, I was able to handle a tarantula!

Carol Edwards – Overcoming my fear of spiders

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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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How to Stop OCD Messing with your Studies!

Do you forget information and worry there’s a fault with your memory? Do you have fears you didn’t read or write everything correctly? Do you doubt yourself and believe your academic future is in trouble?

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When OCD starts messing with your studies, it’s time to take action.

Below are 7 tips to help you get back on track!

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Tip 1 

Do the 3 A’s: (1) Acknowledge the intrusive thoughts (2) Accept they are there (3) Allow them to come and go with anxiety (it will come down by itself once it’s reached a peak, usually within the hour).

Doing the 3 A’s helps intrusive thoughts filter out more smoothly; blocking them or fighting them makes them push through more. When they push through more, it increases the strength of obsessional doubts and keeps you in a never-ending circle of what-ifs? Identifying at this point that intrusive doubts are based on nothing concrete and not worth investing your; instead, concentrate on moving away from the doubts by focusing on the present. Think about what needs to be done (studying) and without stopping to ask yourself or others why your memory seems to be “failing” you (this is a fear, not legit); no re-reading or double-checking either, this holds you back (not easy I know, but worth it… the obsession is nonsensical anyway). Choosing to study in the present guards against your falling into the trap of additional reassurance and checking compulsions, which fuels the obsession.

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Tip 2 

Be aware that your experiences are showing you otherwise.

Think about your past achievements, your tutor’s appraisals, your ongoing efforts to present good work, and the ruling out of any medical cause (memory). Next, remind yourself that your proven abilities outweigh problems with memory and recall (and other obsessional worries too). Hector Peguero quotes: “The moment you feel it creeping in, it’s time to act.” In other words, step back from ruminations, tune into your intuitive self and observe the situation. Put in some perspective and decide to shift your mental state by taking a break (grab a glass of water and breathe in some fresh air), and then go back to your studies while simultaneously practising the 3 A’s.

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Tip 3 

Be mindful. Use the STOPP method.

The STOPP method can help you self-regulate and tune back into your natural abilities. 

S — STOPP

T — TAKE A BREATH

O — OBSERVE: What am I thinking? What am I reacting to? What am I feeling?

P — PUT IN SOME PERSPECTIVE. See the bigger picture. Is this a fact or an opinion? Is it fear related? How would someone else see this? How do I move on from this? What strategies do I have? What is my new perspective?

P — PRACTICE WHAT WORKS: What’s the best thing for me to do right now? Can the 3 A’s work for me? Can I remind myself that intrusive thoughts are not worth investing in? How else can I manage this situation rationally for a more favourable outcome? What would I advise someone else to do in the same situation? Generate as many ideas as you can and use what works in the moment.

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Tip 4 

If doubts continue to plague you, use the downward arrow technique to find a deeper level belief. The one below is on memory, but you can change it to something else, like, “What’s so bad about not double-checking?” Adapt as you go along…

Ask yourself the same or similar questions until you get your answer. For example:

What’s so bad about having a memory problem?

If I cannot learn, I cannot be knowledgeable.

What’s so bad about that?

Without knowledge life would be boring.

And what’s the worst about that?

I would have no prospects and therefore no future, just a mere existence.

Finally, what’s the worst about that?

I would be seen as a failure and my life would be pointless.

Notice how this technique shows a fear-related problem. In this instance, you can eliminate the fear by tuning in to your natural ability and instead listen to your intuitive self. Bring out your strengths! Write them down on sticky notes and stick them to your computer, your door, your wall (wherever you like) and remind yourself that you’re a brainbox with a normal memory and get past the negative hurdle… jump back up to tips 1, 2 and 3 and get back into perspective!

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Tip 5 

If you find you doubt your doubts, use the yin versus yang approach!

The “Yin versus Yang” method is useful for tackling doubts and fears which can interrupt your new healthier beliefs and perceptions where you argue with the positive belief. The argument often includes “what ifs?” and “buts” which can hold you back. Therefore, using a zig-zag technique allows you the opportunity to argue the two beliefs effectively.

YIN: Healthy positive choice of belief. YANG: Belief based on doubt/worry

Yin → My learning is productive with sound memory and knowledge; I have gained and retained my learning objectives so my recall is intact.

Yang ← What if that’s not the case? It doesn’t feel like that.

Yin → The facts say so and I do recall information following my revision periods, I just doubt that I don’t.

Yang ← What if I’m kidding myself? What if this isn’t really the case?

Yin→ My experiences are showing me otherwise.

Yang ← But there’s always a chance that I could be wrong and my memory is faulty.

Yin → Well I could be wrong; yet, living with uncertainty in the face of an obsession is healthier than struggling with never-ending doubts and what-ifs, and let’s face it, OCD is a fraud anyway. It’s more likely I’m stressed due to exams coming up and worrying about what my future prospects will be.

Yang ← But how can I be sure? I mean I know I’m stressed, but this is beyond what I can bear.

Yin → I can go around this circle only to come to the same conclusion which is that my problem is one of emotional reasoning which has caused me to believe my memory is suffering. I can get past this with a rational mind. By altering my emotional responses to more logical responses, I can help myself. For example, I can decide to live with uncertainty when doubt creeps in and bear with associated anxiety until it reduces naturally; or carry on worrying and getting nowhere fast.

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Tip 6 

Exposure scripts. These scripts can help you live with uncertainty.

There has to be no reassurance statements in an exposure script, otherwise it won’t work. This is because reassurance statements are compulsions, and compulsions strengthen the obsession. 

Record your script on to a loop tape and listen to it several times each day (say 20 minutes 4 times a day). The one below is an example. Notice how there are no reassurance statements. The intention is to become bored with the OCD threat since boredom and fear cannot be experienced together (Fred Prenzil), so one usually overrides the other. Your job is to get bored with your irrational fear…

Exposure Script: “In life the truth is that I can never have 100% certainty about anything. No matter how many times I go over the doubts in my mind, it can never be ascertained that my recall has or hasn’t failed me. Neither can I be certain of ever being released from the possibility of having no prospects or future stability due to poor memory. Besides, it cannot be made certain that my re-reading, double-checking and seeking reassurance rituals will save me from having a fruitless life, all without knowledge and wisdom. Further, the more I listen to my OCD and let it determine the limiting factors of my behaviours and actions, the more my symptoms will intensify. The sooner I recognise that OCD thoughts are based on irrational fears that serve emotional rather than sensible reasoning, the sooner my recovery will start; or improve.”

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Tip 7

When in doubt jump back up and re-read tips 1-6 or whichever tip helps you most… most of all, enjoy being a student, you have everything going for you!!

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