OCD SYMPTOMS: WHEN DOES EXPERIENCING BIZARRE THOUGHTS, IMAGES OR URGES BECOME A DISORDER?
Many studies have found that 80% to 90% of the population has had intrusive thoughts on occasion. Some have had an impulse to run someone over while peacefully driving down the street, to jump off a bridge or to cry out an obscenity. It has occurred to others to do something inappropriate to someone and there are many other thoughts that go through people's heads for no reason at all.
Below is a brief summary of a study conducted by Purdon and Clark (1992) where abnormal or bizarre thoughts were experienced by males and females in a university sample. The percentages show the frequency at which these sometimes strange, other times embarrassing or disgusting thoughts, images or urges are experienced by normal populations.
Extracted from "Obsessive Intrusive Thoughts in Non-clinical Subjects. Part 1, Content and relation with depressive, anxious and obsessional symptoms". Behaviour Research and Therapy 31, 713-720
If you experience intrusive thoughts, images or urges similar to these that you find difficult to dismiss, you may be suffering from OCD.
Sylvia Buet specialises in the treatment of Obsessive Compulsive Disorder (OCD), particularly
in Pure Obsessions such as harming, sexual and scrupulosity (religious). In CBT therapy, you will be able to better understand why you developed OCD, while the majority of people who may also have the same thoughts, imagesor urges from time to time, did not.
What are obsessions?
Typically, a first panic attack seems to come "out of the blue" occurring while a person is engaged in some ordinary activity like driving a car or walking to work.
For a diagnosis of OCD to be made, the client must exhibit either obsessions or compulsions, in accordance with the diagnostic criteria of DSM-IV-TR. There need not be both obsessions and compulsions, although they occur together as a rule.
Obsessions must fulfill the following criteria in order to be diagnosed as OCD:
1. Thoughts, impulses or recurring and persistent images considered intrusive or inappropriate, which cause significant anxiety and discomfort. These intrusive thoughts, impulses, or images are not restricted to mere excessive preoccupation about real life problems. If they were just normal worries, the diagnosis would likely be of Generalised Anxiety Disorder, commonly known as GAD.
Notwithstanding, there are certain obsessions that can be mistaken for simple worries. In these cases, a detailed assessment is in order. Here are some examples of bizarre obsessions Sylvia treated in the past: A man who was obsessed that his eyes would remain turned inside out, a woman who thought she was walking strangely, with one foot higher than the other and another client who could not understand how the brain could form words and how she could manage to speak or utter words.
2. The second feature is that obsessions are ego-dystonic and not simple worries. Ego-dystonic is a term used in CBT, which means that the content of the thoughts, images or urges a person has are inconsistent with his system of beliefs, and therefore perceived as utterly out of character or alien. Worries, on the other hand, are ego-syntonic. That means that an individual does not find the thoughts totally inconsistent with her belief system. Another critical difference between worries and obsessions is that obsessions are normally resisted and worries are not.
The degree of intrusion will be determined by the importance attached to the experience, its consequences and its implications. When there are great consequences and implications, a series of automatic negative thoughts will be activated. An example of this is, "If I think about killing my girlfriend, maybe I will lose control and end up killing her for real".
3. People try to either ignore or suppress these thoughts, impulses and images. They may also try to neutralise them with other thoughts or actions. It is important that there is some resistance present for obsessions to be considered as such. It is logical for people to try to neutralise something that is bothering them and causing discomfort. There are several ways of neutralising obsessions. One is by developing rituals and compulsions designed to eliminate the emotional response produced by the thought, image or impulse.
4. The final consideration is that obsessions need to be viewed as the product of a person´s mind. The client must not think that they were imposed as in the case of thought insertion. A small percentage of people with OCD do not consider their obsessions to be extravagant or irrational, although they clearly are. In these cases, such ideas, which are overestimated in an almost illusory manner, must be sufficiently refuted. This is called OCD with poor insight.
Examples of obessive thoughts associated with pure obsessions
These are some of the obsessive thoughts, images or urges that Sylvia has treated in the past:
- What if I bump into a small child and kill him?
- What would happen if I lost control and said something insulting/abusive/ridiculous? (this could also be a common worry in those with social anxiety)
- What would happen if I suddenly did something dangerous like jumping off a balcony, throwing myself in front of a speeding car, stabbing myself to death, etc?
- Did I turn off the oven?
- Maybe I got pregnant from using my father's towel.
- I see an image of me stabbing you in the eye, while we are talking face to face.
- Did I just drop my keys while posting the letter in the letter box?
- I feel the urge to spit on people when I am being introduced to them.
- I feel the urge to strangle my wife while she sleeps.
- I have the image of sexually abusing a small child.
- What if I am gay?
- Did I kill a person while driving?
- Did I rape my girlfriend while sleeping?
- Did I sin against God?
These obsessions are not usually followed by behavioural rituals. Instead, you may exhibit avoidance, reassurance and safety-seeking behaviours, as well as neutralising thoughts in order to cope with the distress generated by these kinds of thoughts, images or urges (obsessions).
If you feel distressed and find it difficult to dismiss any of the above or similar thoughts, images or urges, you may be suffering from OCD. Sylvia specialises in OCD, with or without rituals. No matter how frightening, embarrassing or distressing your obsessional thoughts may seem to you, it is likely that Sylvia has encountered a client with similar thoughts. She has treated hundreds of cases of OCD over the past 20 years with a high degree of success, regardless of the complexity of symptoms.
What are compulsions?
Compulsions are acts that may be performed either in public or in secret, which are in most cases associated with the presence of obsessions. They are usually performed in a ritualistic, stereotypical way and are known as compulsive rituals.
DSM-IV-TR offers the following definition for compulsions:
1. Behaviours or mental acts of a repetitive nature that an individual feels compelled to perform as a response to an obsession, or according to a certain set of established rules.
It is important to bear in mind that compulsions can be not only behavioural, but also be performed in one´s mind. Some known mental rituals are repeating certain words or phrases, praying, making calculations and singing.
2. Compulsions are aimed at preventing or reducing discomfort, or preventing negative events or situations. When it seems necessary to try to neutralise obsessions, the acts aimed at neutralising them are described as compulsions or rituals. These rituals can be either behavioural or mental.
Although an individual´s active resistance level is considered essential for diagnosis, sometimes resistance to obsessions is barely present in chronic cases. This may be the result of years spent attempting to control the behaviour without success.
A client may perceive rituals as a way to prevent contamination, ensure perfection or free himself from catastrophic consequences. Paradoxically, while the client engages in rituals to escape discomfort, Walter and Beech (1969) demonstrated that anxiety and discomfort occasionally increase shortly after the rituals and, in the long run, maintain OCD symptoms.
Types of OCD
There are different sub-types of OCD.
1. CONTAMINATION OBSESSIONS LEADING TO EXCESSIVE CLEANING OR WASHING (e.g. Ritualised washing of hands, whole body or certain body parts, excessive cleaning of house, objects and clothes.
The most common type is the one involving contamination obsessions and 47% of those suffering from OCD experience this kind of obsession. The most common rituals are washing and cleaning. People with this kind of OCD usually complain about feeling dirty (mental pollution) or contaminated if they do not ritualise. They may fear catching a disease or contaminating another person.
Ordinarily, Sylvia sees cases with this type of OCD only when people can no longer function because the OCD interferes in nearly every aspect of their lives due to its severity. It is advantageous to begin a course of therapy to deal with this type of OCD in its early stages. Allowing it to intensify until it is out of control will make treatment more difficult.
2.DOUBTING OBSESSIONS LEADING TO EXCESSIVE CHECKING.
Another type of OCD involves doubt and pathological responsibility. It is manifested through checking and verification rituals. Many clients benefit from CBT for this common type of OCD.
People suffering from doubting OCD present with a lack of self-trust, and commonly feel guilty and extremely anxious, unless they ritualise. An example of doubting OCD is the individual who checks the gas cylinder, doors or windows over and over again. This client is afraid of causing HARM to himself, another person or their property. Therefore, rituals are performed in order to neutralise and compensate for the perception of risk associated with the self-image of not being a careful, responsible or decent person.
Checking compulsions are normally associated with verifying that one has not harmed either oneself or others as well as concern for safety. People tend to check windows, doors, lights or faucets. Both doubt and intolerance towards uncertainty are at the root of these types of rituals. Some doubts are not related to harming; they may be related to giving someone the wrong amount of money or making a mistake with figures at work, for example. In these cases, the obsession is rooted in a fear of someone else being disadvantaged or harmed psychologically, emotionally or financially. There is no fear of someone being harmed physically.
OCD-related pathological doubt may be manifested in many different ways. Some individuals with OCD, when driving a car, will turn back repeatedly and drive over the same route to check to see if they have run over a pedestrian. They have great anxiety and will check the news the following day to make sure there was no "hit and run" accident they may have been involved in. It is possible this individual will go to the opposite extreme and avoid listening to or reading the news altogether.
3.The next type of OCD is HOARDING. People with this type of OCD are obsessed with the accumulation of useless things like trash, paper and various different objects. In their minds, they overestimate in a catastrophic way the things that might happen if they stopped accumulating objects, as well as the negative consequences their "carelessness" or "negligence" might have.
4.ORDER, PRECISION, AND SYMMETRY OCD may also be accompanied by pathological slowness, based on the obsessive idea of perfectionism. Nevertheless, the obsession with symmetry and order are normally associated with "magical thinking". Typical compulsions are to organise clothes, paper, personal affairs, in a very specific, stereotypical manner, following a certain order and respecting certain fixed positions.
Two different themes may be behind this type of OCD. One is excessive perfectionism, leading to people seeking the feeling of being "in a perfect state", in order to feel good. Not engaging in rituals of order or symmetry is likely to be associated with feelings of annoyance and irritation.
Sometimes, the compulsion to keep things in a certain order is associated with fear of causing indirect harm to someone (harming obsessions). Rituals of symmetry or order are then performed in order to AVOID HARM but much of this obsession is based on magical or superstitious thinking.
5.PURE OBSESSIONS WITHOUT COMPULSIONS. This type is one of the frequently-occurring ones. Sylvia particularly specialises in treating this type of OCD. Pure obsessions are categorised as sexual, aggressive/ harming or religious (also termed scrupulosity).
Sexual obsessions include fears that one might be gay, one might sexually abuse a child or one might do something sexually inappropriate to another adult.
Aggressive obsessions include fears that one may harm small children, one may hurt someone in the family or one might self-harm/taking their own life, without having control over the action. Examples of these kinds of obsessions are the fear of stabbing or hitting your wife or children, that you may jump from a high place and kill yourself, run over a pedestrian or hit someone while driving.
Religious obsessions and scrupulosity include the fear of sinning or committing blasphemy, fear of going to Hell if he does not adhere to what is perceived as religious perfection or that God and the afterlife may not exist.
Some obsessions do not fall into any of these categories (e.g. fear of not being able to speak or fear of going blind). This does not mean they cannot be treated.
The wide variety of compulsions extend beyond those associated with checking, cleaning or washing. Some clients repeatedly touch certain objects, swing or move in a stereotypical way, spit, organise objects according to specific rules, or avoid certain people or situations. Rituals can also be done mentally (e.g. counting, checking in the mind or praying).
Sylvia has extensive experience in treating complex cases using a method deemed appropriate to each individual client. The treatments methods all meet the approval of applicable professional organisations, NICE (National Institute for Clinical Excellence) for example.
CBT treatment for obsessive compulsive disorder and pure obsessions
The most effective treatment for Obsessive Compulsive Disorder, with or without rituals, is Cognitive Behavioural therapy. Improvement rates can reach 80% with a 20% complete remission rate. As with any therapy, results vary depending on the client.
CBT is the treatment of choice for OCD, with two behavioural interventions, exposure and response prevention receiving the highest scientific endorsement. Once a thorough assessment and formulation of your particular case has been carried out, a course of Cognitive Behavioural therapy for OCD will comprise of the following components:
1.Psychoeducation. In treatment, you will learn why you may be suffering from OCD, what maintains the problem, what the treatment entails, success rates, how to avoid roadblocks and the need to commit to doing homework assignments. You will be informed and motivated throughout the course of therapy. The goal is not to eliminate the obsessions but to learn how to avoid engaging with them.
2.Exposure Therapy. Exposure therapy may be in vivo or in imagination (imaginal exposure), and the goal is habituation. Clients face the feared situations, allowing information to be processed. Rituals, neutralisation and avoidance of any kind only maintain dysfunctional beliefs and obsessions by way of negative reinforcement. In vivo exposure is when you are asked to do something you tend to avoid, for example touching the door knob, but you are required to do it for an extended period of time, over and over again, until no distress is experienced (e.g. Continuously for 1 hour).
When in vivo exposure is not possible, imaginal exposure is used. This is particularly relevant for those who have pure obsessions without rituals and fear becoming perpetrators of sexual abuse, of hitting or hurting someone or who fear sinning against God. This type of exposure is carried out with a narrative you write detailing your worst fears, recorded on a tape, which you will be asked to listen to repeatedly each day until your level of distress decreases. For the to be effective, the person must not use any rituals, avoidance, safety, distraction, rationalisation, neutralisation or relief-seeking behaviours while the exposure is taking place. Practising safety behaviours will result in the exposure therapy failing and the OCD symptoms being maintained.
3.Cognitive therapy is also used although Sylvia tends to offer behavioural therapy first in order to observe quick improvements at the beginning but this will depend on the case. Cognitive restructuring is applied in order to address the interpretations which have not changed with exposure, or the beliefs that are likely to lead to a future relapse. If you are experiencing only pure obsessions, without rituals, cognitive therapy plays an important role on top of the use of behavioural interventions. In therapy, Sylvia will help you identify and modify certain personal beliefs that maintain your obsessions and rituals or that block the course of treatment such as, "If I say this out loud, it proves that I´m a pervert", "If I don´t obsess, that means I don´t care about what I might do to my children", "If I feel the urge to hit my child, that means I will do it and I will become a monster for doing it".
4.Behavioural experiments are also used to gather evidence about the accuracy of your beliefs or predictions e.g. "if I don't ritualise, I will not be able to relax for the next 12 hours".
5.Response Prevention. Response prevention appeared in 1966 with Victor Meyer, in the United Kingdom. Before that moment, the OCD prognosis was rather bleak. It was then observed that, for an OCD treatment to be effective, a combination of exposure and response prevention therapy was needed. Exposure alone is not enough to treat obsessions with compulsions. It must be implemented alongside response prevention, which means not only encouraging clients to refrain from performing rituals, but also shunning any kind of neutralisation or avoidance.
6.Eliminating maintaining factors such as safety and reassurance seeking behaviours, avoidance, confession, rationalisation and analysis, neutralising thoughts or images.
The treatment is conducted in a manner that takes into account your own resources to cope with the interventions so as to make it as comfortable as possible. However, the rules for exposure and response prevention must be followed carefully. Therefore, you must be very committed to completing all the homework tasks assigned in session in order to fully benefit from your CBT treatment.
7.Medication. Some drug therapies are effective in reducing obsessions. New antidepressants, such as the SRIs family (e.g. fluoxetine, paroxetine, sertraline and fluvoxetine) are all recommended for OCD. They have fewer side effects than the tricyclic antidepressants, which were once prescribed (e.g. imipramine or chlorimipramine). Approximately 50% of those seeking CBT therapy for OCD are taking some kind of medication, which improves the efficacy of CBT particularly when OCD is accompanied by severe depression.
Sylvia is up-to-date with the last and most effective treatments for OCD. She will not use relaxation techniques or thought stopping to manage your symptoms. While these techniques are still used to treat OCD, they do not help if you are suffering from this type of problem. Sylvia will only use scientifically validated interventions which have been proven effective to treat OCD.
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