BRIEF GUIDE TO OCD TREATMENT

Definitions of OCD

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1. Writer's Definition: An anxiety-spectrum disorder constituted by a reliable mechanism, in which inferential confusion seeds obsessional doubt (obsessions), which provoke anxiety/distress, which compel problem-solving (compulsions), which reinforces the initial inferential confusion. This cycle generally continues unabated or in a deteriorating form until effective treatment is applied.
    

2. ICD-10 Definition: "The essential feature is recurrent obsessional thoughts or compulsive acts. Obsessional thoughts are ideas, images, or impulses that enter the patient's mind again and again in a stereotyped form. They are almost invariably distressing and the patient often tries, unsuccessfully, to resist them. They are, however, recognized as his or her own thoughts, even though they are involuntary and often repugnant. Compulsive acts or rituals are stereotyped behaviours that are repeated again and again. They are not inherently enjoyable, nor do they result in the completion of inherently useful tasks. Their function is to prevent some objectively unlikely event, often involving harm to or caused by the patient, which he or she fears might otherwise occur. Usually, this behaviour is recognized by the patient as pointless or ineffectual and repeated attempts are made to resist. Anxiety is almost invariably present. If compulsive acts are resisted the anxiety gets worse."
   [Source: World Health Organization. (2016). International statistical classification of diseases and related health problems: Vol. 1. Tabular list (10th revision, 5th ed.).]
    

3. DSM-5 Definition (abridged): The presence of obsessions, compulsions, or both.

   1. Obsessions are defined by (1) and (2). (1) Recurrent or persistent thoughts, urges, or images that are experiences at some time during the disturbance and intrusive and unwanted, and that in most individuals caused marked anxiety or distress. (2) The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e. by performing a compulsion).

   2. Compulsions are defined by (1) and (2). (1) Repetitive behaviors or mental acts that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. (2) The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive

   3. The obsessions or compulsions are time-consuming (1 hour+/day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
      [Source: American Psychiatric Association. (2022). Obsessive-compulsive and related disorders. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).]

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Mechanism of OCD

 

1. Inferential confusion: a reasoning error in which the mind confuses an inference (an imagined possibility) with reality (the sensory-based probability). This reasoning error enables doubt, of which obsession is the voice.
    

2.  Obsessions: intrusive and distressing thoughts, images, or beliefs that stem from inferential confusion.

   • Obsessions are generally the expression doubt, manifesting as “what if _____” questions around feared potential catastrophic outcomes.

   • Obsessions are highly individual, though for many individual follow certain common themes based on social and cultural values and general human fear responses.

   • Due to inferential confusion, obsessions appear (“feel”) genuine/true and urgent to the individual, even if the individual logically understands their improbability.
      

3. Anxiety/distress: psychological and somatic response to the obsessions, which are experienced as unpleasant and prompt a behavioral response by the individual.

   • is an anticipatory fear, and distress can manifest to include other negative emotions such as panic, horror, shame, disgust, and guilt.

   • Anxiety/distress occurs as an automatic and natural response to obsessions. Despite being a natural response, the anxiety/distress is presenting correct information, as it is occurring in response to obsessions which in turn are based on the faulty reasoning of inferential confusion.
      

4. Compulsions: Physical or mental behaviors designed to solve the problem presented by the obsession(s), and in turn neutralize the anxiety/distress.

   • Compulsions primarily manifest in three forms: 1) physical compulsions (behaviors visible to others), 2) mental compulsions (rumination and analysis) 3) avoidance (of situations/thoughts/things that trigger the obsession and anxiety/distress).

   • Compulsions are defined by their function rather than by their form. In other words, they are defined not by the specific behavior, but by whether that behavior is designed to neutralize the obsession and anxiety/distress. If the function of a behavior is to alleviate, counter, resolve, or otherwise neutralize the obsession or subsequent anxiety/distress, then it is likely a compulsion.
      

5. Repetition: Continued inferential confusion, obsession, and anxiety/distress resulting from the individual having behaviorally responded to, and thus reinforced, the illusory feared potential outcome. 

   • Due to the neurological malfunctions inherent with OCD, as well as to the impossibility of solving a problem that is not a real problem (but only appears to be based on the faulty reasoning of inferential confusion), compulsions do not and cannot bring conclusion or long-term relief from the obsessions.

   • Instead, compulsions reinforce inferential confusion, in turn leading to further obsessions and subsequent anxiety/distress. This cycle is often repeated without end until treatment (Exposure and Response Prevention) is successfully applied.

 

Types of Treatment:

 

1. Exposure and Response Prevention (ERP): the primary evidence-based treatment for OCD. ERP involves:

   1. Exposure to obsessions and the anxiety/distress.

   2. Prevention of response via compulsions; not solving the problem presented by the obsessive thought, nor attempting to relieve the anxiety/distress, nor react in any other way to the obsessions.

2. Inference-based CBT (I-CBT): Modern evidence-based OCD treatment, largely compatible with ERP though with some key differences in underlying conceptualization and practice. I-CBT involves:

   1. Substantial exploration and identification of the mechanism of OCD

   2. Mapping out the role of inferential confusion and imagination in creating obsessional doubt

   3. Treatment via reconnecting with the senses and here-and-now

3. Acceptance and Commitment Therapy (ACT): A generalist therapy that is evidence-based for a wide range of mental illness, including OCD. ACT involves:

   1. The practices of "defusion" (observing thoughts as separate from self) and acceptance (allowing feelings and emotions to be felt)

   2. Orientation to personal values and structuring plans to enact those values via behavior

   3. Mindfulness practices of being in the present moment and experiencing the "self-as context" (known as the "observing self" in Buddhism)

 

Brief Guide to OCD Treatment

(Not intended to be an effective substitute for working with a therapist specializing in OCD and/or with a psychiatrist)

 

1. Preparation:

   • Assess and survey: Identify all obsessive themes present. Identify the obsessions and primary compulsions for each theme. It can be very helpful to work with a therapist for this task. A therapist can help explore whether a concern is rooted in reality of in inferential confusion, and may administer assessments such as the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) to support assessment.

   • Discuss doubts and barriers: If there are any lingering doubts about whether a topic is obsessive, discuss this with a therapist.

   • Orientation to treatment: Once an OCD topic/theme has been identified, acknowledge that thoughts on this topic are going to be distorted, illusory, and will not accurately represent reality, no matter how genuine/true they appear or “feel”. Acknowledge that continuing to try and solve the problem through rumination or behaviors can and will only make it worse.

   • Commitment: Recognizing that the topic is obsessive, and that compulsions can and will only worsen the obsessions, and that ERP is the logical and evidence-based treatment for obsession, mentally acknowledge that implementing ERP will require practice (exertion) and short-term sitting with distress and uncertainty. You can do this, and it’s helpful to be committed before beginning.
      

2. General (passive) Exposure:

   • Acknowledge: When obsessions arise, briefly acknowledge that these thoughts are OCD (which means that the content is distorted and that problem-solving will not help). Identify obsessions not on whether they “feel” true or not, but instead based on their mechanism and form. If the thought is intrusive, distressing, repetitive, and based on doubt, then it’s OCD.

   • Allow triggers: When you encounter triggering content (i.e stimuli that prompts obsessions), intentionally continue to engage with or otherwise expose yourself to that trigger. Don’t avoid or psychologically run from the triggers. Go towards them confidently.

   • Allow obsessions and anxiety/distress: Allow obsessions to occur and allow the anxiety/distress to be present without resolution. Allow yourself to feel the anxiety/distress both somatically and psychologically, though do not feel that you need to intentionally direct attention towards it. Obsessions and the subsequent anxiety/distress, though deeply unpleasant, pose no genuine threat and require no intervention, as they are both based on a distorted perception of reality stemming from the inferential confusion.  The obsessions and feelings won’t last forever, even if it feels like they will.
      

3. Response Prevention:

   • Don’t engage with the obsessive content: Resist the mind’s desire to perform compulsions. In other words, do not try and solve the problem. Nothing you do to solve the problem (whether the problem is that you might be contaminated, or a moral failure, or sick/unhealthy, or ruined, or want to harm those you love, that you might feel anxious forever, etc.) is going to work. Because nothing works (and nothing ever will) in resolving the problem presented by obsession, cease trying to solve the problem. Specifically, do not change behavior to try to solve the problem presented by the obsession. Do not intentionally analyze or ruminate on the problem. And do not avoid things that trigger distressing thoughts.

   • Gently engage with real (non-obsessive) problems: Go engage with something else that’s real, something that you would be doing if these thoughts weren’t present. Continue to gently take your attention back to a real problem in life – such as reading a book, responding to an email, planning for dinner, working, taking a nap – without trying to distract yourself from the distressing thought. Obsessive thoughts will continue to arise as you do this – that’s completely fine – just continue to engage with the real problem and allow the distressing thought to be there as you do this.

   • Repeat: Continue this practice regardless of how many times intrusive thoughts arise, or what form they take. Continue to gently shift your attention to a real problem to engage with, allowing the obsessions and anxiety/distress to simply be there as you do so. Remember, nothing you do will work in solving or finding resolution with the problem presented by the obsession.
      

4. Active Exposure (use for higher frequency and more distressing obsessions; do not use for 'OCD about OCD' subtype)

   • Targeted exposure: Twice a day, set a timer for 15-30 minutes, and during this time invite the obsessions and anxiety/distress to appear. Intentionally think about triggering content (i.e. triggers for the obsessions), with the goal of prompting obsessions and anxiety/distress. As obsessions arise, completely allow them and request that the mind provides you with further obsessions. Once the time goes off, return to practicing standard response prevention for the rest of the day.

   • Targeted somatic experiencing: As above, set a time for ten minutes. During this time, focus your attention intently on the somatic or psychological anxiety/distress. If the sensation is in your body, focus on that part of the body. If the sensation is in your mind, focus on the dysphoria, panic, racing thoughts, or whatever other manifestation it appears as. Exert willpower to feel the anxiety/distress as closely and intently as possible. Try and feel the distressing emotions/sensations the same way you would try and ‘hold on to’ a euphoric or pleasant sensation; bask in the anxiety/distress. As you do this, you should experience a paradoxical effect in which the anxiety/distress diminishes over time, though it is not immediate. If ten minutes is not long enough to do this successfully, increase the duration to twenty.

 

 

Resources

 

Overview of OCD: https://medlineplus.gov/obsessivecompulsivedisorder.html (National Institute of Health)

 

Types of OCD: Common Types of OCD | NOCD (NOCD)

 

Neurobiology of OCD: Understanding OCD | Obsessive-Compulsive and Related Disorders | Stanford Medicine (Standford University)

 

What are compulsions: OCD Compulsions: What They Are and How to Manage Them (NOCD)

 

Mental Compulsions: https://www.psychologytoday.com/us/blog/think-act-be/201601/mental-rituals-in-obsessive-compulsive-disorder (Psychology Today)

 

General Treatment Guide: https://iocdf.org/about-ocd/ocd-treatment-guide/ (International OCD Foundation)

 

Introduction to ERP: https://iocdf.org/about-ocd/treatment/erp/ (International OCD Foundation)

 

Psychopharmacology for OCD: https://pmc.ncbi.nlm.nih.gov/articles/PMC4143776/ (National Institute of Health)