Obsessive-Compulsive Disorder

Obsessive-Compulsive Disorders Defined

Obsessive-compulsive Disorder is a well-named condition.  The obsessions relate to our thoughts; specifically automatic repetitive thoughts that can’t be ignored for very long.  Many disorders experience obsessive thoughts, but not as a primary feature of the illness.  For example, schizophrenics are often obsessed with their paranoid or grandiose thoughts, but it is not a primary feature of the disorder.  Schizophrenics are not aware of their thoughts being unusual or abnormal, while the person with OCD perceives their obsessions as abnormal.  Obsessive thoughts for the OCD sufferer tend to center about particular behaviors; for example, hand washing, counting and touching.  The obsession is typically paired with magical thoughts; such as the avoidance of something bad happening if the doorknob is touched exactly three times.  Compulsion refers to the need of a person to perform a particular motor behavior.  It is the realization of the obsessive thought.  In the example above, uncontrolled thoughts of being dirty are the obsession, and the compulsion is the actual repetitive hand washing.  Persons with OCD can voluntarily stop the compulsive behavior, but tension will increase until they perform the particular motor routine, complete with the expected magical outcome.

An excellent comment was left by “Nervous Nelly” as to what differentiates a “habit” from a “compulsion”.  Neuropsychologically, there is no known concrete difference between a habit and a compulsion.  Both words describe behaviors that are so well-learned that conscious control is not required.  Both are performed in the absence of cues or prompts within the environment.  Neither depends on some event in the environment to signal the start or stop of the behavior.  So what is the difference?

There is increasing research evidence that compulsions are involved in a very tight feedback loop between two areas of the brain.  Habits appear less tightly bound to this feedback loop; exhibiting more activation in other areas of the brain.  There is increased evidence that a compulsion is a maladaptive subset of the behaviors we label as habits.  Much of the common usage difference between a “habit” and a “compulsion” is in terms of functional outcome.  Habits of going to work and taking out the garbage are not typically viewed as bad, but the sniffing of cocaine is uniformly considered a bad habit.  Habits are labeled as good or bad, but compulsions are nearly always used in the context of being maladaptive and bad.  Occasionally, people speak of an “artistic compulsion”, but even here it suggests a maladaptive love of art.  It appears that a primary difference between habits and compulsions are societal values.  Even murkier is the distinction between compulsions and “bad habits”, such as gambling and substance abuse.  Compulsion fits these behaviors neatly, but not typically used in conjunction with these “bad habits”.  To summarize, the main difference between a habit and a compulsion are cerebral localization and societal values.

As with so many mental disorders, there is a huge gap between mild and severe sufferers.  Mild sufferers with OCD are often successful people, detail oriented, who are perceived by others to be stuffy, cold and particular.  This is close to what is termed an Obsessive-compulsive Personality Disorder.  Those with severe OCD are completely debilitated.  Immersion into the obsessions and compulsions is so complete that nearly all necessary adaptive behaviors are shoved aside by the illness.  The degree to which they are bound to the compulsion is heart wrenching.  Severe OCD sufferers are helpless in the face of their obsessive thoughts and compulsive behaviors.

What can be done for those afflicted with Obsessive-compulsive Disorder?  Obsessive-compulsive Personality Disorder is rarely treated, as those afflicted are generally successful people.  Often this group is brought in by a loved one who can’t cope with the bizarre behavior and cold attitude.  Treatment of mild OCD entails the identification of maladaptive and irrational aspects of their behavior.  These patients often fixate and obsess on the psychologist’s words, and the increased awareness into this tendency promotes increasingly flexible thinking.  The psychologist will increasingly have the patient practice looking at the big picture; the global aspects of their environment.  It will always be difficult for these mild sufferers to break from small details and scan the macro features of situations.  Treatment of severe OCD is generally performed on an inpatient psychiatric unit.  These unfortunate people require medication to stabilize their condition.  There has been increased research into severe OCD as being primarily a psychotic disorder, and not a subset of anxiety disorders.  Severe OCD may respond to major tranquilizers, whereas this class of medications is not effective for mild sufferers.  Working my way through school as a psychiatric tech, I was shocked at the level of functional disability engendered by severe OCD.  I would not be surprised if subsequent research proves that mild and severe OCD are two distinct disorders, sharing some symptom overlap, but with distinctly different treatment choices and outcomes.

The Basics of Psychotherapy

Many people ask, sheepishly, how psychotherapy really works.  The term “therapy” is mentioned constantly in the media as a short form of the word “psychotherapy.”  It’s natural that people are curious about something that is seemingly ubiquitous, yet apparently defies easy explanation.  There is nothing magical or new about psychotherapy.  Like most medications, however, there are aspects of its intrinsic functioning that remain a mystery.  The nebulous and fleeting words strewn about a psychotherapy session appear, mysteriously, to be less important than the conditions demanded by the therapeutic frame.  The “frame” of psychotherapy refers to all aspects of the session divorced from the actual words used within the session: for example, cost, time, place, office policies, etcetera.

Whatever the psycho-therapeutic school of thought, there are set features that are standard across most styles and techniques.  The most important element of effective psychotherapy is the promise of confidentiality.  Without a solid confidential therapeutic base, psychotherapy is nothing more than a Socratic conversation for hire.  One’s life may be blessed by many intimate trusted contacts, yet one cannot divulge literally everything to any one friend.  There are always social consequences, and consciously or unconsciously, all of us must monitor and filter the content of our conversations.  I do not believe that this encompassing social information management is strictly selfish.  As often as not, the filtering of information is used to protect the feelings of others.  Having intimate  friends is certainly important to one’s mental health, yet even the closest of relationships may be of little use when one’s situation is altered by psychological suffering.  For instance, most of my patients are very conscious of becoming a “burden” to others through ventilating their distress.  Unless the intimate attachment is based upon this sort of negative ventilation, the voicing of complaints may alter the basis of the friendship.  Existing social support may be lost.  For this reason alone, close friends are often of little help when psychological distress becomes significant.

Confidentiality is the boiler plate of psychotherapy.  Psychotherapy research of the last 50 years is convergent in revealing that the particular therapeutic technique employed is less important than confidentiality in achieving a favorable patient outcome.  Part of these findings may be explained by the decreased social risk obtained by ventilating to a professional.  Another aspect of these findings may be explained by the very nature of psychotherapy technique.  Each school of psychotherapy tends to focus on particular features of the human experience, yet similarities do exist.  Broadly, psychotherapy is dedicated to resolving problems that negatively affect one’s life.  The relative importance of thoughts versus behaviors differs, yet nearly all seek to identify “maladaptive” thoughts or behaviors that lower a person’s psychosocial functioning.  Many schools, such as Rogerian, eschew the whole notion of maladaptive, yet even the most positive and uplifting psychotherapy is seeking to alter one’s thoughts and/or behaviors.  It is unlikely that anyone would pursue psychotherapy as a treatment if they perceived their thoughts and behaviors to be wonderful.  Many schools of psychotherapy are better at appearing more positive and uplifting than others, but the mission is essentially the same.  For example, a new form of psychotherapy is termed “coaching.”  This form of psychotherapy/counseling even eschews the whole notion that it is a psychotherapy!  As in Rogerian therapy, there is a strong accent on the therapist being positive and proactive.  The word “coaching” is synonymous with “instructing.”  It appears that some people would forgo the benefits of an intimate attachment to a therapist, in order to avoid being perceived as a “psych case.”

Schools of psychotherapy are targeted towards individuals, couples or families.  While the number and relation of the individuals is different in various schools of thought, the mission to discover less than desirable thoughts and behaviors is the same.  Many therapists and schools of thought voice a focus on “communication.”  I am at a loss to know what else could be a focus of psychotherapy.  All psychotherapy assumes communication as essential to the experience, since no therapeutic school pretends to work with comatose or catatonic individuals.  Nonverbal behavior communicates a great deal to the therapist and others involved in the session.  Verbal and nonverbal communication is the very stuff with which we work, such that the notion of “communication” being a special focus is a bit absurd.  The greatest difference between psycho-therapeutic schools of thought are that each tend to emphasize particular features (subsets) of the therapeutic experience; thoughts versus behaviors and individuals versus groups.

If I may draw on the medication analogy again, the use of different forms of psychotherapy is similar to considering side effects in proscribing a particular medication.  If we know that two medications will work equally well to cure a condition, which should be employed?  The medication with side effects better tolerated by a particular individual would be the obvious choice.  For example, the new class of antidepressants called SSRI’s are very good, yet most cause serious reversible symptoms of sexual impairment.  If the patient is very sexually active, it might be better to use an older, though less effective, antidepressant without the unwanted sexual impairment.  Similarly, group psychotherapy is the most obvious choice to reduce social anxiety, yet initially it may be the worst form of treatment.  Exposed to the stimuli they fear the most, a group of people, the patient may experience recurrent trauma as a consequence of this treatment.  For this person, it is better to lessen the initial anxiety with individual psychotherapy, and then save the finishing touches for group psychotherapy.

The basics of psychotherapy are centered about confidentiality, a solid frame, and the identification of unwanted thoughts and/or behaviors.  The choice of which psychological technique to employ is similar to choosing amongst equally effective medications.  The choice of interventions should be based upon the comfort level of the particular patient, in light of their unique situation and lifestyle.

Further Considerations

Perhaps you have read my last post “Psychotherapy 101” or “The Basics of Psychotherapy.”  The post “Psychotherapy 101″ is an introduction  into fundamental aspects of psychotherapy.  It also attempts to dispel common myths regarding psychotherapy.  I am satisfied with the post’s information, but a bit unhappy with its tone.  Perhaps in my rush to dispel the “fruit and nut” aspects of psychotherapy, I did not give an accurate description of its softer side.

Even though most people seek psychotherapy to solve particular problems, there are those whose mission is to grow as a person.  It is easy to categorize these people under the “problem” label, since a desire to grow as a person assumes a certain degree of dissatisfaction with one’s life.  Perceived in another way, one may regard these seekers of growth to be satisfied with their lives, yet eager to exceed the boundaries of their current existence.  It is less improving a bad thing than making a good thing even better.

Personal growth through psychotherapy is not problem oriented or solution focused.  There is no mountain of empirical literature to guide the psychologist’s movements.  It is a free style exploration of one’s existence.  Psychodynamic therapists have an interesting perspective on this form of exploration.  They maintain psychotherapy is the construction of a story that both the patient and therapist agree upon.  It is a simple sounding phrase, yet its meaning tends to enlarge as it is turned over in the mind.

The path of the growth oriented patient is less clear than the problem-oriented one.  The explicit goals and techniques of traditional psychotherapies render the measurement of progress and success rather easy.  The only goal of growth psychotherapy is to exceed one’s current psychological limitations.  Neither the psychologist or patient knows how or when the process will end.  The psychologist may perceive the patient as complete, but only the patient has the privilege of considering themselves complete.  In traditional psychotherapy, the psychologist is largely the owner of this privilege.  For example, once the patient stops smoking or their mood is brighter, the psychologist will pronounce success.  Psychotherapy is considered complete with the resolution of the problem-oriented goal.  In growth therapies, only the patient will truly know when they have reached their goal.

Many growth-oriented therapies eschew goals as an unnecessary stifling of personal exploration.  Perhaps this is based upon the assumption that the goals of an incomplete person will be incomplete as well.  It may be true that one has to reach a certain level of psychological sophistication to formulate reasonable goals.  While this concept rings true for many high functioning people, it is not very applicable to those with more fundamental problems.  Working with victims of head injury, the formulation of any goal may be a great victory for the patient.  Lacking awareness into their deficits, the psychologist must maintain the privilege of  controlling the nature and extent of the treatment.  Growth-oriented psychotherapy assumes good cognitive functioning.

Growth-oriented psychotherapy is likely most beneficial to those whose work and home-life are generally satisfactory.  Personal growth work is easily derailed by current emergencies and old traumas.  Personal growth as a goal is certainly noble and worthwhile.  The time and expense are considerable, and the commitment is extraordinary.  The shared experience of building an autobiography is very powerful.  One cannot help but be altered by the experience.  The person emerging from this process has yet to be revealed.  It is hoped that greater awareness will bring greater clarity, and the clarity will strength our purpose.

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