An obsession is an unwelcome thought or image that reiterates in a patient’s mind that its cessation is largely outside of their voluntary control. These obsessions can be difficult to ignore. The thoughts may be disturbing which can make a person feel distressed and anxious.
A compulsion is something that is thought about or carried out repeatedly in order to relieve this anxiety. These rituals can remain hidden or may be obvious. Obsessive-Compulsive Disorder (OCD) can be seen as a perception of reality based on a phobia or fear, that drives the patient to react by means of compulsions. These can be thoughts, specific formulae or actions, in an attempt to reduce their fears. The usual observed solutions adopted by obsessive-compulsive patients in order to handle panic-laden circumstances is to either avoid such situations or to carry out compulsions or rituals. Certain situations, people or objects can be so fear-provoking that they are avoided completely (Gibson, 2019, 2020; Portelli, 2007).
Rarely covered in early clinical literature in psychology, it was not until the early 1980s that OCD was studied – it was generally considered a very rare condition until then. It has, however, been recently ranked as tenth in the cause of worldwide disability in the Global Burden of Diseases study (Murray & Lopez, 1997) and OCD is now considered the fourth most common mental illness in many western countries.
Obsessive-Compulsive Disorder presents itself in many guises, and certainly goes far beyond the common misconception that it is merely a little hand washing or checking of light switches. Although these are common OCD compulsions, such perceptions fail to acknowledge the distressing thoughts that occur prior to such behaviours and also fail to highlight the utter devastation that constant compulsions (no matter what they are) can cause.
Although there are infinite forms of OCD, it has been traditionally considered that a person’s OCD will fall into one of five main categories, with themes often overlapping between categories too. There are infinite expressions of OCD, it can impact on any thought, any subject, any person or any fear, and frequently fixates on what is important in a person’s life.
- A need to clean and wash because something or someone is contaminated
- The constant need to check yourself or your environment to prevent damage, fire, leaks or harm
- Thoughts which are repetitive and upsetting
- Not feeling able to throw away useless or worn out items
- You repeatedly pull your hair out, causing noticeable hair loss
- You feel increasing tension before you pull your hair out
- You feel relief by counting
- Repeated hand washing
- Cutting or self-harm to achieve pleasure or to sedate pain or anger
- Repeated or never-ending desire to check
- Eating disorders e.g. vomiting, bulimia and binge eating
A Brief Strategic Understanding Of The Evolution of OCD
The Big 5 – The Positions from which OCD Develops:
1. Doubt – This begins from a doubt that triggers a series of protective rituals that either repair or prevent the problem of fear. Example: I wore a green shirt to that test so I must wear it again to succeed again. Through this process, the irrational becomes rational by means of the irrational process. Also, evidence is created for the belief.
2. A Rigid Belief or ideology, morality or superstition – for example, I should say a prayer for being so unkind to that person. Take a shower to relieve me of sexual impulses. I must carry out prayers each day so as to receive God’s blessing (propitiatory). I must read the horoscope before I meet this guy etc. Vomiting or bulimia also are created in this process.
3. When something Rational Becomes Irrational – This process is created when someone puts too much thinking into trying to foresee all the consequences to some decision. This process while grounded in some reality becomes wholly irrational when it is used to the max. This creates an inability to act and instead of helping, it invalidates our ability to act.
4. Preventative Health-Based Phobia – This is usually triggered to prevent something from happening, like an illness or infection for others, the family or us. In this process, the preventative process turns into a true phobia.
5. Trauma – In this case we see people doing things to sedate themselves from trauma. It is very important to let them pass through the trauma so the compulsions can be completely done away with.
How Common is Obsessive-Compulsive Disorder?
We can now safely say that worldwide, there are literally millions of people affected by OCD. Up to 50% of the cases fall into the severe category and less than a quarter are classed as mild cases.
It is believed the frequency of OCD occurring in the western population is between 2.5%-4%, but as we have said previously, we now consider this to be four times higher (Gibson et al., 2016a, 2019b, Nardone and Portelli, 2013). When speaking to our patients, we see that many of them affected by OCD unfortunately suffer in silence.
This silence often occurs through embarrassment or fear of being labelled, often unaware that their suffering constitutes a recognised dysfunctional perception and a diagnosable condition. Patients with OCD suffer with very distressing thoughts and rituals, some of which can breach many of the taboos of civilised society, for example, the fear of murdering a child, being a paedophile, or the fear of injury to friends or family members. In most cases, when the disorder is a structured sequence of rituals, the phobia that originally triggered the desire to perform rituals fades into the background.
OCD is expressed in many different ways and there are as many ways of expression as there are people who develop it. The most common patterns are an obsession with dirt and germs, leading to hand and body washing and then ultimately, the avoidance of all of those objects that the patient presumes to be contaminated. This does not always mean places that are actually dirty, but those spaces and places which will be perceived by the patient to be dirty.
To the general population, some of those surfaces, implements and places will in actual fact seem extremely clean and utterly safe.
We also regularly see patients washing their hands excessively and they can sometimes completely avoid leaving home, eventually becoming housebound due to their morbid fear of germs, dirt and infection.
Another common and frequent pattern we observe is an obsessional doubt, followed by the compulsion to check things repeatedly. Instead of resolving the patients uncertainty, the checking and rechecking increments the doubt and often contributes to even greater doubts, which lead to further checking. These doubts can also create a feeling of guilt for having forgotten something crucial, or the fear of having committed some immoral action.
Patterns of thinking in OCD can also involve intrusive obsessional thoughts without any clear compulsion, known in some spheres as ‘Pure O’, or pure obsession. However, as we will explain later, obsessions such as the fear of abusing children or harming someone can lead to an alarming amount of avoidance.
Patients may avoid children, even their own children or nieces and nephews, and they may even avoid roads where there are schools or children playing, to avoid triggering the intrusive thoughts. This form of avoidance can very easily be adapted to any fearful obsession (Gibson, 2016, 2019, 2022; Pietrabissa, 2013, 2016, Portelli, 2007, 2013; Nardone and Portelli, 2013, Portelli and Papantuono, 2018).
On the other hand, many of our patients attend the clinic due to their compulsive need for symmetry or precision (which leads to sluggishness and inefficiency). They may also desire to order things in a specific way. Some can suffer with well-documented hoarding or religious obsessions. We can safely say that OCD symptoms vary greatly and widely from individual to individual, and this mixture and difference, leaves the therapist in a position to necessarily and creatively develop new and effective treatment methods for such a disorder.
- Relationship Intrusive Thoughts
- Sexual Intrusive Thoughts
- Magical Thinking Intrusive Thoughts
- Religious Intrusive Thoughts
- Violent Intrusive Thoughts
- Bodily Obsessions
Symmetry and Orderliness
The need to have everything lined up symmetrically and ‘just right’ is the compulsion, the obsessive fear might be to ensure everything feels ‘just right’ to prevent discomfort or sometimes to prevent harm occurring (see Magical Thinking).
For example, those affected will spend a lot of time trying to get the symmetry ‘just right’ and this time-consuming checking can result in them being extremely late for work and appointments. They may also become mentally and physically drained if the compulsions take a considerable amount of time. The sufferer might also avoid social contact at home to prevent the symmetry and order being disrupted which can have a negative impact on social interaction and relationships.
The above list categorises the more common forms of Obsessive-Compulsive Disorder and some of the fears associated with them. But this is by no means an exhaustive list and there will always be other OCD types not listed here. So if you are experiencing distressing and unwanted obsessions or compulsions not listed here, this does not mean it is definitely not OCD. If they impact significantly on your everyday functioning, these could still represent a principal component in the clinical diagnosis of Obsessive-Compulsive Disorder and you should consult a doctor for a formal diagnosis.
The fear of being dirty or the fear of contamination is a common obsessional worry. This fear can be of contamination that may not only effect themself, but that might also cause harm to a loved one. The common compulsions might be to wash or clean or avoid. Common contamination obsessive worries and compulsions include:
- Public toilets
- Shaking hands
- Door handles
- Dead skin
- Teeth brushing
- Outside air
- Public telephones
- GP surgeries
- Eating in public locations
- Staircase banisters
There is also a less obvious form of OCD know as ‘mental contamination’. Feelings of mental contamination can be provoked when a person feels badly treated, physically or mentally, through critical or verbally abusive remarks. It is almost as if they are made to feel like dirt, which creates a feeling of internal uncleanliness – even in the absence of any physical contact with a dangerous or dirty object.
A distinctive feature of mental contamination is that the source is almost always human, unlike ‘contact contamination’ that is caused by physical contact with inanimate objects.
The person will engage in repetitive and compulsive attempts to wash the dirt away by showering and washing which is where the similarities with traditional contamination OCD return – the key difference is that the contaminated feeling does not need to come from a physical contact, and often it is from feeling alone with mental contamination.
Some Famous People with OCD
OCD is often discussed in the media with well-known celebrities such as David Beckham who is commonly referred to as a celebrity with OCD.
Others might include:
- Billy Bob Thornton
- Natalie Appleton
- Charlize Theron
- Leonardo DiCaprio
- Niall Horan
- Nicholas Cage
- Howard Stern
- Jessica Alba
When Common-Sense Becomes Distorted
“The human mind is so flexible that it can go crazy and by means of its own reason.”
– G. Lichtenberg
The logic underlying Obsessive Compulsive Disorder is based on the fact that something, which is rationally correct to do, can become, irrational and unhealthy just through the number of times it is ritually repeated. This repetition eventually becomes exasperating and it is at this point that a person can move from the logical to the seemingly illogical.
It may be healthy to be careful if you are washing after using the toilet but it is unhelpful to wash for hours after because of an irrepressible doubt that you may have touched something dirty and then after having washed for a long time, you feel that you have not washed enough, and thus become forced to wash again. Or, before going to bed it is certainly healthy to check doors, taps, gas etc., but it is definitely absurd to wake up several times at night and recheck everything.
It can be healthy to think that you will do well in a test, but it becomes insane when you begin to ritually put in place specific behaviours that should be done over and over again to reassure you.
Seemingly Illogical Behaviour
OCD behaviour can be defined as an overwhelming compulsion to perform behaviours or thoughts in a repetitive and ritualized manner with a view to achieving a reduction in anxiety or fear, or to achieve some specific pleasurable feeling. Suffering from this severe problem will require effective clinical treatment.
The Mental Trap of Obsessive-Compulsive Disorder
If we analyse the mental prison represented by Obsessive Compulsive Disorder we have observed that the attempt to seek reassurance in order to manage a fear or the irrepressible tendency to feel a specific sensation structures a very rigid and persistent problem.
OCD Can Be Experienced When The Obsessions and Compulsions:
- Consume excessive amounts of time in the person’s life
- Cause significant distress and anguish and interfere with daily functioning at home, school or work, including social activities and family life and relationships
The Logic of Rituals In OCD
Reparative – These Rituals done to repair for something
Preventative – Rituals that the patient believes prevent something
Propitiatory – Rituals that ensure all goes well
Pleasure Based – Are done to achieve a pleasurable sensation
Rituals and Sensations
Rituals can be done to generate a specific sensation of pleasure or to reduce a sensation such as fear or pain and once again this is extremely important information for the clinician to utilize as it will help them build an effective, brief intervention that is extremely focused.
Depending on the structure of the ritual an essential and unique aspect of BST is having devised several counter-rituals specifically prescribed to fit the different typologies of compulsive symptomatology (Gibson and Portelli, 2015,2014; Nardone and Portelli 2005, 2013, 2014).
With a success rate of 85% in treating eating disorders our model of Brief Strategic Therapy now represents a ‘Copernican Revolution’ in the field of Psychological treatment.
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