Understanding OCD

Obsessive-compulsive disorder (OCD) is a surprisingly common psychological problem. Only 25 years ago, it was believed to be a relatively rare condition. In part, owing to newer and more effective treatments for it, OCD is now known to affect many millions of people at any given time.

If left untreated, in most cases, OCD can straightjacket a person's life with immobilizing anxiety. What's worse, many people with OCD will develop depression that not only intensifies suffering but often complicates and lengthens treatment.

Nevertheless, as debilitating as it can be, when treated with skillfully done, cognitive-behavior therapy (CBT) that emphasizes a crucial method called exposure and response or ritual prevention (ERP), OCD's anxiety and depression producing grip can be significantly loosened.

In general terms, the main features of OCD are intrusive, horrific, and relentless irrational thoughts or images (obsessions) that drive tremendous anxiety and specific, usually excessive, repetitive, or unrelated behaviors (compulsions) that are performed in an effort to neutralize or reduce the anxious thoughts, feelings, and sensations.

What's more, obsessions can be triggered by specific, unwanted thoughts (like "Am I a pedophile?") as well as external events (such as touching things thought to be dangerous — like doorknobs, or seeing certain things like a clock reading 9:11).

Moreover, rituals can be either overt or observable (e.g., washing, cleaning, checking, repeating actions, repetitive movements, etc.) and/or covert or hidden (e.g., changing unwanted thoughts or images into more acceptable ones, counting, excessive praying, etc.).

Some of the more common obsessions include contamination phobias and fears of getting sick, or spreading germs or toxins to others; hurting people by doing something impulsive to harm them, or accidentally hitting them with one's car, or by not being responsible enough for other's safety; and blasphemous or criminal thoughts.

Common compulsions or rituals include washing; making sure things are safe by checking locks, appliances, etc.; repeating actions until it feels safe; asking for excessive reassurance from others; counting; praying; and transforming anxious thoughts into less disturbing ones.

Also, a central feature of OCD is avoidance of things that trigger anxiety.

Finally, OCD often involves a significant component of superstition. For example, not changing channels on the TV or radio until the person sees or hears something safe, or waiting until the clock reads 9:12 to start doing something instead of doing it at 9:11.

Basically, OCD is classified as one of two types: with insight — meaning the individual understands that the OCD beliefs are irrational or untrue, and without insight — meaning the individual thinks the OCD beliefs are probably true. In extreme cases, insight can be totally absent, making the OCD beliefs rise to the level of delusional intensity. Obviously, good insight carries a better prognosis than poor or absent insight.

(For how to beat OCD without drugs, please see my previous post.)

In essence, when someone has OCD, his or her brain's danger detection region is hypersensitive and dramatically overreacts to certain triggers thus launching a massive, often panic-level anxiety attack (i.e., an exaggerated or inappropriate fight or flight reaction). At the same time, the brain region that usually indicates safety is very sluggish and slow to signal "all's clear."

Hence, the OCD sufferer will experience needless or greatly exaggerated surges of intense anxiety related to terrifying, irrational thoughts that drive him/her to engage in rituals in an effort to drive down anxiety and restore feelings and sensations of safety. In other words, since the person's "automatic" safety signaler is very slow to relieve anxiety, he or she will try to do it "manually" with a ritual.

In the long run, however, rituals don't work consistently to reduce anxiety due to a process called "negative reinforcement" (not to be confused with punishment) that, ironically, further energizes the brain's anxiety triggers and makes its safety signaler even weaker and slower.

Neuroimaging studies using PET scans have identified several hypermetabolic, brain structures that are almost always associated with OCD. Specifically, a neural pathway referred to as the supraorbital-cingulate-thalmic circuit — the SOCT circuit — appears overactive in brain scans of people with OCD. (Other neural pathways sometimes referred to in brain biology research into OCD include the “cortico-striatal thalmamo-cortical circuit, or CSTC; and the prefrontal cortico-striatal-thalmo-cortical circuit, or PFC-STC.)

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Interestingly, when OCD sufferers were randomly given either an SSRI antidepressant or underwent intensive, CBT for OCD with ERP — exposure and ritual prevention — those who improved significantly had follow-up PET scans that showed much less activity in their SOCT circuit. Thus, regardless of whether or not the person got better through CBT or took medication, both therapies produced essentially the same result on brain activity. In sum, this is reasonable evidence that the SOCT circuit is important in the phenomenology of OCD and both drugs and ERP reduce its activity. (See Baxter’s pioneering research cited below for more technical information on this subject.)

The prevalence of OCD might be explained on the basis of its evolutionary importance. Clearly, to a certain extent, some aspects of OCD must be very adaptive. Specifically, the ability to notice danger and recognize safety is hugely advantageous.

As it was with our remote ancestors, our recognition of danger and safety involves at least three psychological dimensions — namely, cognitive appraisal (thoughts and images about the situation), emotional activation (feelings of danger and/or safety), and sensory stimulation (viscerally sensing the danger or the safety).

Usually, people are good at discriminating between the psychological experience of danger and safety. That is, we typically experience congruence among these psychological zones. Therefore, when we perceive safety, we have no significant anxious or intrusive thoughts, dreadful emotions, or anxious sensations. Our minds, moods, and sensations are all in alignment and reflect a deep feeling of safety and security in the situation. And when we perceive actual danger, we usually have worries about the situation, fearful feelings, and a lot of nervous system arousal that results in various physical sensations of anxiety, such as muscle tension, clenching gut, dry mouth, racing heart, rapid breathing, shaking, sweating, etc.

Most people are able to accurately detect dangers and threats as well as know and sense when they're safe. This is because the parts of their brains that function as this danger/safety detection mechanism (probably, in part, the SOCT circuit) work properly and don't often send "false alarms" or fail to detect and signal real safety.

In cases of OCD, however, this danger/safety neural mechanism seems to malfunction and in more severe cases goes seriously haywire. In people with OCD, their brain's danger and safety detection system cannot be trusted. It frequently signals danger where there is none and then fails to sound the "all's clear" until often lengthy or elaborate rituals are performed. Indeed, most people with OCD do rituals until they feel safe even though there is no real danger in the first place.

Still, people suffering from OCD try to achieve a specific, physical sensation of safety and have great difficulty grasping factual safety. For example, a person who feels dirty or contaminated might wash extensively, far beyond the point of actual cleanliness. Thus, someone with this specific type of OCD will wash (and wash, and wash) until he/she senses and feels clean even if takes a long, long time to achieve the desired sensation. In most cases, especially when the illness is first developing, the person will eventually feel clean enough (i.e., safe from germs, disease, toxins, etc.) at which time the ritual stops. Unfortunately, as mentioned above, this only strengthens anxiety and other OCD symptoms because of a process called negative reinforcement.

Briefly, negative reinforcement is defined as an increase in a behavior (e.g., washing) because it removes or prevents an aversive stimulus or event (i.e., anxiety or sensations of being dirty). So, if a person feels dirty and washes until he/she feels clean, then washing will be strengthened because it works to remove the unpleasant feelings and sensations of being dirty. Therefore, the removal or prevention of anxiety and distressing sensations negatively reinforces washing and/or other rituals.

Unfortunately, in cases of OCD, this negative reinforcement pattern leads to tolerance for rituals similar to how people become tolerant of habit-forming substances. That is, over time, people need to increase their rituals for them to keep working to reduce anxiety.

This is like drug-dependent people needing to take increasing amounts of the drug they're dependent on to get high or feel good. This is because suppressing withdrawal symptoms negatively reinforces taking the addictive drug just like neutralizing anxiety negatively reinforces rituals (e.g., washing). Also, when people with OCD resist doing rituals, their anxiety intensifies which is akin to a substance-dependent person experiencing withdrawal.

Of course, the fastest way to neutralize the pain of withdrawal is to take another dose of the stuff the person is dependent on. Similarly, the fastest way to neutralize the pain of anxiety due to OCD is to do a ritual. Just as it is with actual chemical dependence, the pain of OCD “withdrawal” must be experienced to break the cycle. The only way out of it is to go through it.

So figuratively, a person suffering from OCD will need to go through “withdrawal” by not doing rituals. Hence, ERP is the treatment of choice to break the cycle of OCD much like “detox” is necessary to break the cycle of addiction. Also, as with chemical dependence, depending on the unique case, OCD “withdrawal” can be either a “cold turkey” process or a more gradual tapering of the rituals.

Again, for a more detailed discussion on doing ERP, please check out my previous post, “How to Beat OCD Without Drugs (It's Simple but Not Easy)."

Remember: Think well, act well, feel well, be well!

Copyright 2015 Clifford N. Lazarus, Ph.D.

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This post is for informational purposes only. It is not intended to be a substitute for professional assistance or personal mental health treatment by a qualified clinician.