BRIEF GUIDE TO OCD TREATMENT

Definitions of OCD

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1. Writer's Definition: An anxiety-spectrum disorder with neurological and behavioral etiology, in which unwanted and distressing thoughts/images ("obsessions") prompt repetitive and unsuccessful attempts to resolve the content of the obsessions and neutralize the distress ("compulsions"). Obsessions often involve doubt over a feared catastrophic outcome, and are experienced as real and possible despite the individual logically being aware that they do not agree with their content. Compulsions are defined by their function, in that they are mental or physical behaviors designed to solve the problem presented by the obsessions and neutralize the distress. 
    

2. ICD-10 Definition: "The essential feature is recurrent 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. Neurological and Learned Cognitive Distortions: A series of maladaptive mental processes, reasoning errors, and neurological dysfunctions which produce and maintain obsessions and compulsions, which include:

   • 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.

   • CSTS (Corcio-Striato-Thalamo-Cortical) Circuit Dysfunction: A primary neurological dysfunction indicated in the development and maintenance of OCD, impacting heightened threat signaling and difficulty registering completion. 

   • Inflated Responsibility: A reasoning error in which the mind overestimates how much control the self has over a situation or outcome. This reasoning error enables and maintains compulsions, regardless of their inefficacy. 

   • Catastrophic Appraisal: A mental process in which unwanted thoughts are treated as fundamentally meaningful, revealing, or dangerous. 

   • Cognitive Fusion: A mental process in which an individual is merged with their thoughts, experiencing them as "real" and identifying with them regardless of their content. 

   • Perfectionism and Intolerance of Uncertainty: Traits, often learned, that treat imperfection and uncertainty as unacceptable and/or requiring remediation. 
      

2.  Obsessional Doubt (Obsessions): Intrusive and distressing thoughts, images, or beliefs often focused on feared potential catastrophic outcomes, which stem from the underlying neurological and learned cognitive errors present with OCD.

   • 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.

   • 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.

   • Anxiety 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 cognitive distortion, obsessions, and anxiety/distress result 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, compulsions do not and cannot bring conclusion or long-term relief from the obsessions.

   • Instead, compulsions reinforce the cognitive distortions underlying obsessions, in turn leading to further obsessions and subsequent anxiety/distress. This cycle is often repeated without end until treatment is successfully applied.

 

Types of Treatment:

 

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

   1. Psychoeducation on the mechanism of OCD and course-of-treatment.

   2. Assessment of the specific obsessive themes and identification of the core fears behind each obsessive theme.

   3. Assessment and identification of mental and physical compulsions.

   4. Implementation of response prevention; cessation of compulsions.

   5. Identification of triggers and specific distressing content, mapped on to an exposure hierarchy 

   6. Targeted, intentional exposure to triggers and distressing content.

   7. Ongoing identification of maladaptive underlying beliefs, hidden or covert compulsions, or life stressors and tailoring of treatment to these barriers.

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. Psychoeducation on the mechanism of OCD through the lens of inferential confusion.

   2. Assessment of the specific obsessive themes and compulsions.

   3. Psychoeducation on how obsessions are built on a distrust of the senses, overreliance on possibility/imagination, and irrelevant associations, and identification of how someone's OCD uses these cognitive distortions to trick them into believing the obsessional doubt.

   4. Cessation of compulsions through orientation to here-and-now sensory input (as opposed to orientation to obsessional doubt and trying to resolve the feared catastrophic outcome). 

   5. A (usually written) exploration of the sensory-based, real-world narrative and how that differs from the obsessive narrative. 

   6. Ongoing engagement with the sensory-based narrative and here-and-now sensory input, and tailoring of treatment to remaining inferential confusion. 

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, in which thoughts are seen as separate from self ("I am not my thoughts") and are neutrally observed as they arise and fade, without one having to behaviorally engage with them. Defusion focuses on utilizing thoughts as tools, and only engaging with them on the basis of whether they are helpful, rather than on the basis of whether they "feel" real. 

   2. The practice of "acceptance", in which emotions are seen as temporary and passing states that can be allowed and fully felt, regardless of their short-term discomfort. Acceptance is behaviorally defined as making no effort to change reality as it is in the present. 

   3. Mindfulness practices of being in the present moment (not in the future, as with worry, or the past, as with regret)  and experiencing the "self-as context" (known as the "observing self" in Buddhism)

   4. Identification of and orientation to personal values, through a series of experiential practices designed to clarify one's own personal values. 

   5. Use of these personal values to guide behavior through structured practices.

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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)