OBSESSIVE-COMPULSIVE DISORDER (OCD) has two essential characteristics: obsessions and compulsions. Intrusive thoughts, images, and urges come into one’s mind involuntarily. If you are vulnerable to developing OCD, these can be the trigger for obsessions. External stimuli, such as coming into contact with dirt, can also trigger obsessional fears. Compulsions are the behaviours people do to make the problem go away.
Obsessions include contamination fears, an intolerance to asymmetry and imperfection. Other obsessional fears include being gay, transgender, a paedophile, or having mistaken intentions to hurt others or oneself. These are known as pure-intrusive thoughts or pure O. Also, one’s attention to a specific part of the body and its functioning can cause a lot of distress. Such awareness is known as a somatic obsession. The heart beating and fearing it is irregular is another example of it—also, breathing, eye-blinking, staring and a crawling sensation on the skin.
Compulsions include checking, straightening, praying, ruminating, reassurance-seeking and washing. However, the person doesn’t know or trust that such actions are not the long-term solution to ridding themselves of the thoughts they cannot control. It is hard for them to give up the compulsions even when they are aware because it’s a temporary solution despite being the wrong one. They get anxiety relief momentarily, but unfortunately, the actions do not make intrusive thoughts go away. Instead, compulsions reinforce that there is a real danger when there isn’t. Consequently, the problem keeps going in a circle, strengthening the obsession, making it more challenging to manage.
Doctors sometimes prescribe medication to people who have OCD. It is usually one of the selective serotonin reuptake inhibitors (SSRIs) that are also for depression. Since serotonin levels in the brain decrease in OCD and depression, SSRI medication helps maintain a more balanced level. Consequently, it supports better mood and reduces obsessive thoughts. In that case, it acts well as an aide to active therapy for many people.
Cognitive-Behavioural Therapy (CBT) and Exposure-Response Prevention (ERP) are used to treat OCD. CBT helps change irrational thoughts, feelings and behaviours for better outcomes and helps prepare for ERP. The latter is the well-known evidence-based therapy designed to prevent people’s actions in response to intrusive thoughts. For instance, when people do ERP, they agree to face their fears in small steps – this is exposure. When facing obsessions, they further agree to resist compulsions – this is response prevention. Over time, it helps them build a tolerance for anxiety and leads to reduced symptoms or remission.
The process of habituation is the desired effect in ERP, showing that a person has understood the connection between developing fear related to the obsession and doing compulsions to reduce anxiety as a result. In other words, they see that performing rituals increases fear and that such actions need to be prevented in breaking that connection. To maintain their gains, a therapist usually provides a client with a relapse-prevention blueprint after a course of treatment.
When ERP Doesn’t Have The Desired Effect
One thing to consider is that not all people take well to ERP. Or they may be held back. For example, when clinical depression prevents treatment from moving forward, a therapist might put active therapy to one side until the person feels better. The habituation process can also affect treatment progress when people become overly preoccupied with their obsession and ritualising. In other words, they can become so immersed in the obsession that imaginative involvement can shift the problem to a term described as dissociation peculiar to OCD (Soffer Dudek et al., 2018). First, absorption is the repressed attempt (ritual) to prevent a perceived threat from happening. Second, the more someone does the ritual, the deeper the absorption becomes; hence habituation and recovery being affected.
Stay tuned for my book about alternative treatment methods for people who do not take well to ERP.