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Logo: OCD Recovery Center

Comprehensive Treatment for Primarily Obsessional OCD

By Dr. Christian R. Komor
OCD Recovery Center

Part 1: Comprehensive Treatment for Primarily Obsessional OCD

Obsessive Compulsive (OC) Spectrum Disorders are, for the most part, genetically determined neurological disabilities. Due to their chronic nature they can be compared accurately to disabling diseases such as Diabetes, Epilepsy, Parkinson's Disease or Alzheimer's Disease. OC disorders differ in that the symptoms and signs of the disorders are primarily internal and difficult to observe from the outside so that the sufferer often feels isolated and misunderstood.

All obsessive-compulsive disorders from Hypochondriasis to Trichotillomania to Obsessive Compulsive Disorder (OCD) itself have in common a biological predisposition in the brain toward obsessive thought. The form that this obsessive thought takes seems to be determined in part by where in the cortical-striatal-thalamic circuitry of the brain the damage or malformation has occurred. Obsessive thoughts most frequently have to do with sexuality, religious issues, harming others, health concerns, checking, ordering, arranging, symmetry, contamination hoarding or various sounds, words, phrases or songs becoming "stuck" in the individual's awareness.

Obsessions are normal thoughts exaggerated in the OC sufferer with increased duration and intensity. Everyone has unwanted thoughts some of the time. In OC disorders these thoughts are simply magnified. For example, most people at one time or another have wondered about their sexual orientation, or felt concern about something unusual they noticed about their body. Like a small pea slipping through a loosely woven net, these thoughts are briefly considered and then discarded as unimportant or a resolution (scheduling a visit to the doctor) is initiated. For OC individuals it is as if the brain net is too tightly woven of very fine mesh so that many thoughts get stuck and some thoughts become so stuck in the "brain net" that they seem impossible to dislodge. Such obsessions can grow to gigantic proportions so that the sufferer ends up unable to function at work, socially, or even perform routine self-care tasks. Such obsessive thoughts are particularly distressing. The inner torment experienced can best be compared to what one might feel a few minutes before one's plane crashes to the ground after a catastrophic engine failure. At the OCD Recovery Center we have developed specialized tools for recovering from what is know as Primarily Obsessive OCD or O-OCD.

Compulsions are the part of Obsessive-compulsive Disorder that receives the most attention from researchers to the media. On the other hand it is the obsessive mode of thought that links all OC-spectrum disorders together as a family. There are many people in our society who are anxious and many who are compulsive, but it is the quality of obsession that at generates creates the suffering experienced by people with OC-Spectrum disorders. Obsessions essentially have two parts: the original unwanted thought and the mental ritualizing or obsessing that attempts to "undue" to unwanted thought. In OC language, unwanted intrusive thoughts are often referred to as "hits" of "spikes".

Obsessive thinking is not just limited to our primary obsessions (germs or illness, causing harm to others, organization, etc.). Like Alice in Wonderland, people with OC disorders may go down dozens of obsessive "rabbit holes" every day - becoming "stuck" and ruminating over aspects of relationships, work, self-image, diet and exercise, person hygiene, even a dream from the previous night. In combination with our primary obsessions, these mini "rabbit holes" can confuse and torment the OC sufferer and rob life of its spontaneity and enjoyment.

One method of reducing obsessive ruminative thought is to reduce one's general anxiety level and, or avoid situations which create anxiety. If one tends to obsess when staying up late and watching television and earlier bedtime may provide ready relief. If one obsesses about attending social events, practicing breathing as a portable relaxation technique may be most helpful. When we are going into a more stressful period in our lives (e.g. starting a new job, activity or relationship) being prepared and alert for increases in obsessive thinking and working increasing self-care behaviors (exercise, meditation, etc.) can fend off increases in anxiety which would otherwise trigger obsessional thought.

Awareness of anxiety is also an excellent test of whether a thought is obsessive or constructive. If the thought has anxiety attached, or if the individual becomes anxious when asked to not counter the thought with a ritual or mental compulsion, then the thought is very likely an expression of OCD.

It is important to keep in mind that obsessions are like mental quicksand. The more the OC sufferer thinks about them and tries to fight our way out by force of mental effort the more he or she will become stuck in them. Relaxing and reminding ourselves those obsessions are "just thoughts without any real substance" is much better medicine than tightening up and worrying if we will ever stop obsessing. Visualize the obsession like a small cloud - notice it and then let it drift away. Realize that obsessions are of no real consequence - they are just brain static. Meditation, as will be discussed below, is very helpful in this regard.

Below are two diagrams that serve to underscore the nature of obsessions. The first illustrates that although there is often a slice of reality to obsessions, that reality slice we can generally live with. (Planes sometimes crash and people sometimes become infected with HIV, but the frequency of these occurrences is very low.) It is actually the larger slice of obsession that becomes problematic and which we seek to reduce in behavior therapy. The second diagram depicts the "One Second Rule" (see page 50). If one allows the mind to settle on a potential obsessive thought longer than a split second biochemical pathways begin to form which cause the though to "solidify" enough that the obsessive mind can latch onto it.

Obsession Verses Reality

Diagram 1: Obsession Verses Reality

Image representing the mind before a thought enters it.Image representing a thought outside of the mind           Image representing a thought inside of the mind.

Diagram 2: The One Second Rule

An important part of obsessing is what is known as "though-action fusion". In thought-action fusion we come to be convinced that just because we think something that our thoughts will influence real events and circumstances. "If I think about my mother dying it will cause it to happen." Now, there is some recent research suggesting that prayer can have an influence on other human beings. There are also theories suggesting that the electromagnetic energy within our bodies can be transmitted outside of us and into the outside world. These scientifically measurable effects are different, however, from thought-action fusion. Thought-action fusion is a "magical" belief, an expression of our disordered neurology. We can learn to identify it and even to differentiate it from the power of prayer and electromagnetic energy fields. It is not the same thing.

What is important for us to understand about thought-action fusion is that this OC effect occurs because our thoughts stay too long in one place. This is to say, the "average" individual without an OC disorder will think "God hates me" for a brief second and then move on to other thoughts (Perhaps not even noticing the thought as it goes by.). Those of us with OC spectrum disorders have a thought net in our brain that is too tightly woven and our thoughts get stuck. This is how we end up obsessing on seemingly unimportant or irrelevant ideas for long periods of time. The longer we dwell on a thought, the more the brain says "Hey, this must be important! I will set aside lots of file space and focus on this more!" Thus, the longer we stay stuck in a thought, push it away or try to solve it in a thought the more likely it is that that thought will become "fused" with our reality. When thoughts hang around for a long time they get linked to events and we lose our ability to differentiate between thoughts and real events.

To take matters a step further, many if not most individuals with obsessions will have a secondary thought loop that goes something like this: (1) See knife in kitchen - (2) Unwanted thought of stabbing loved one - (3) "I must be a terrible, disgusting person to think such a thought". This final thought, of course, make it a certainty that the individual will attempt to force the original unwanted thought or image out of their mind. This has the natural result of sealing the thought further into consciousness and setting in motion a cycle of perpetual rumination.

Approximately one quarter of OCD sufferers have what is considered Primarily Obsessional OCD of O-OCD (e.g. obsessions are predominant with few or even no compulsive or ritual behaviors that attend them.) Like other forms of OCD, O-OCD is driven by abnormally high anxiety levels. Perpetual doubt further increases anxiety with corresponding increases in obsessions and so on. The situation is not helped by the fact that most obsessions have in them at least a potential kernel of reality. The individual who obsesses that they might kill their child knows that some people have in fact committed this atrocious crime. An individual obsessing about their hearing being damaged by a loud noise can read articles about rock stars and factory workers who have lost part of their hearing for just this reason. It is often helpful to draw a "reality pie" for the individual illustrating how much reality there is to their obsession and how much of the pie (usually close to 99%) is obsession.

At the OCD Recovery Center we have learned that the more "overvalued" the ideation is the more the OC sufferer is likely to believe that the thought has real substance and value. Some O-OC sufferers have more insight into the unreality of their obsession than others, but all have some degree of awareness that the obsessive ideation is not "normal". Many hide the belief because of an awareness that others will not agree or will make fun of the belief if it were exposed.

O-OCDS obsessions come in three general levels or types: Common, Global and Intrusive. Common Obsessions are those that tend to pop up as part of daily living ("Did I just glass in my eye from that jar that my spouse dropped in the other room when I was not even around?") Similar to Type II Diabetes, Common Obsessions cause discomfort, but usually not disability and are usually manageable through obsession inoculation techniques.

Global Obsessions are those pervasive, consuming, life-infringing obsessions that are usually highly disturbing to the individual and make it difficult to function in work, relationships and self-care. Global Obsessions are often frightening and disturbing and many times center around such issues as religion, harming others, sexuality, bodily injury, or timeline distortions.

Unfortunately, many individuals with Global Obsessions have no compulsion or ritual with which to undo or control the unwanted thoughts. This is true helplessness as the thoughts just come unbidden throughout the day and the individual feels powerless to control them. Often such individuals get into various forms of feedback loops as they try to resist or say "No" to the obsessions only to have them increase in response.

People with Global Obsessions are actually less likely than the average person to act on the obsessive thoughts they have. Indeed, most find the thoughts to be particularly tormenting as they run counter to the individual's morals and ethics. Obsessions seem to have, if anything, an inverse correlation character and morals of the person or what is really happening or about to happen in a persons life.

Intrusive Obsessions are less common and often very difficult to remove. Examples of Intrusive Obsessions include songs, noises, images, or phrases that replay over and over in the sufferer's mind and seem impossible to shut off. It is as if the individual's mind becomes caught in an endless feedback loop.

At the OCD Recovery Center we conceptualize obsessive thoughts in general like quicksand. Analyzing the obsession simply makes it worse - just like struggling in quicksand. More of the same leads to more of the same. The more the individual focuses on the obsessions and attempts to figure them out, or struggles against them, the worse they become.

Obsessive tendencies tend to be cyclical based on life-phase, environmental stressors, and even season of the year. Most people with obsessive tendencies do not totally eliminate that part of their personality, but it is possible to reduce the obsessions in strength and frequency so that they are not bothersome. Performing compulsions to attempt to remove and take away the obsessive thoughts only tend to make them stronger.

Our first main task in dealing with obsessions is to separate ourselves mentally from them - to begin to see that we have obsessive thoughts, but we are not our thoughts. A good way to start this process is by writing down the individual's obsessions in list form, rating their intensity, listing what comes before the obsession ("trigger".) and what comes after the obsession ("neutralizing strategy".) Becoming aware of obsessions, when we have them, what triggers them, what course they take and how they lead us to behave is the initial step.

Our second main task is to habituate to the obsession. This is different form desensitization where the individual is learning to accept a feared or anxiety provoking person, place of thing. Habituation can be likened to the process we have all gone through when jumping into a cold lake or pool of water. If we survive the initial shock and persevere by staying in contact with the water we will eventually become "used to it". As this occurs we stop noticing the water and our experience of it blends with our self-awareness so that the water temperature fades in importance until we forget about it altogether. This is what happens in exposure-based behavioral therapy for primarily obsessional OCD.

One important note before proceeding to the "how to" section of this paper. Active treatment for obsessional OCD should not be attempted until the individual is fully committed to do whatever it takes to fight off the OCD. Beginning some of the below exercises and then aborting them prematurely may make the OCD worse - sometimes much worse. Trust must first be established and the individual must be ready to follow through on all instructions of the therapist. Do not expect improvement in most situations until at least 60 days of treatment. This is especially true of Massed Exposure and Attention Training exercises.

Part 2: Exposure and Response Prevention for Obsessions >>


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