Several of the articles on this site have already examined the link between childhood trauma and anxiety. In this article, I want to consider one specific anxiety-based disorder known as obsessive-compulsive disorder (OCD). When a person has this disorder, as its name suggests, s/he suffers recurring obsessions and/or compulsions. I define these below :
OBSESSIONS – intrusive and anxiety creating thoughts, images or impulses
COMPULSIONS – behaviors or mental acts intended to reduce the anxiety the obsession causes (but which, in fact, actually makes the anxiety worse over the long term). Any effect the compulsion has on reducing the anxiety created by the obsession is temporary.
I show below how thoughts, feelings, and behaviors flow into each other to keep the symptoms of OCD going :
OBSESSIONS (intrusive thoughts or images related to contamination, sexuality, danger, morality, etc) >>>>>DISTRESS (eg shame, fear)>>>>>COMPULSION (repetitive behaviors or mental acts aimed at reducing the anxiety created by the obsession)>>>>>TEMPORARY RELIEF>>>>>OBSESSIONS (intrusive thoughts or images related to contamination, sexuality, danger, morality, etc)>>>>> (eg shame, fear)>>>>>COMPULSIONS (repetitive behaviors or mental acts aimed at reducing the anxiety created by the obsession)>>>>>TEMPORARY RELIEF>>>>> and so on…and so on…leading to chronic distress.
In order for a person to be diagnosed with OCD, the following criteria normally have to be met :
a) the obsessions and compulsions cause significant distress
b) the obsessions and compulsions significantly interfere with day-to-day functioning.
c) the behaviors engendered by the OCD take up about an hour a day or more
d) the person with OCD is aware, at least at some level, that his/her behaviors are excessive and illogical
It is, of course, necessary to get a diagnosis from a professional as opposed to trying to self-diagnose.
HOW PREVALENT IS OCD THROUGHOUT THE GENERAL POPULATION?
It is estimated that approximately 2-3% of the population will suffer from OCD at some point during their lives. However, this may well be an underestimate as many people choose to keep their condition a secret. Research indicates, however, that OCD is becoming increasingly common.
Whilst the condition can begin in childhood, its onset is more common in late adolescence. It seems to be equally common in both men and women. However, women are more likely to seek out treatment for the disorder.
OCD can be made worse by stress. Also, those who suffer from OCD often suffer from other conditions as well. These include :
– panic attacks
– specific phobias
– eating disorders
WHAT ARE THE MOST COMMON OBSESSIONS/COMPULSIONS?
In descending order. the most common are :
– checking and cleaning
– needing to ask or confess
– symmetry/ordering rituals
It should also be noted that people often have multiple obsessions/compulsions and these can change over time.
Due to the amount of distress OCD causes, and its link to other serious psychological conditions, if a person suspects s/he suffers from it, it is very important to seek out professional advice.
OCD and the brain :
Brain scans have shown that the brains of people who suffer from OCD are different from people who don’t. These scans show :
there is overactivity in certain brain regions which include ;
– the basal ganglia
– the orbital frontal regions
– the caudate nucleus
Furthermore, it has also been shown that those who suffer from OCD have less serotonin (a neurotransmitter) available in the brain. Indeed, a medication called SSRIs ( selective serotonin reuptake inhibitors) increases the amount of serotonin in the brain and can be an effective treatment for OCD.
There is also thought to be a genetic component to OCD.
However, childhood trauma also plays a part. An individual with a biological/physiological predisposition to developing OCD will be more likely to suffer it if s/he suffers a traumatic childhood.
Various terms have been given by psychologists to what happens in the brain when a person has OCD. Schwartz termed it ‘brain lock’ whereas Rappaport referred to it as ‘a brain traffic jam.’
TREATMENT FOR OCD:
As mentioned above, medications can be given to increase serotonin levels, and, also, decrease brain activity in the relevant brain regions. Cognitive-behavioral therapy (CBT) and hypnotherapy can also prove to be effective.
WHAT IS THE DIFFERENCE BETWEEN OBSESSIONS AND COMPULSIONS?
– OBSESSIONS are THOUGHTS, MENTAL IMAGES, and IMPULSES
– COMPULSIONS are unwelcome and repetitive BEHAVIOURS.
EXAMPLES OF OBSESSIONS – these revolve around eight main themes :
a – CONTAMINATION e.g. ‘I can’t shake hands, I’ll catch a terrible disease’.
b – ORDER e.g. ‘the towels must be exactly in line
c – HARM e.g. ‘that candle might start a fire’
d – HOARDING e.g. ‘I must always keep all my rubbish, otherwise, I could throw away something of value’
e – CERTAINTY e.g. ‘Did I definitely turn off the gas.’
f- NUMBERS e.g. ‘Whenever I turn off a light I must flick the switch 27 times.’
g – RELIGION/MORALITY e.g. ‘Thinking that thought means I’m evil – I must never think it.’
h – SEXUAL e.g. ‘If I think sexual thoughts I am sinful.’
Examples of compulsions are ;
– repeated hand washing
– repeatedly checking gas is switched off
– counting all the cracks in the pavement
– keeping things in order
What Is Pure O?
Pure O (which stands for ‘purely obsessional’) is (at the time of writing) a little known term used to refer to a form of obsessive-compulsive disorder (OCD) ; OCD, as we have seen from other articles that I have previously published on this site, is a disorder that we are at higher risk than average of developing if we have suffered from significant and chronic childhood trauma.
‘Pure O’ manifests as internal, mental rituals that involve a compulsion to obsessively ruminate upon, and to turn over and over in one’s mind, the same repetitive, disturbing thoughts ad infinitum. These intrusive thoughts, which the affected individual finds impossible to dismiss from conscious awareness, are sometimes referred to as ‘spikes.’
Typically, the content of these distressing, intrusive, and unbidden thoughts center upon irrational fears of carrying out behaviors that are abhorrent to one and utterly contrary and antithetical to one’s set of values, ethics, and morals such as rape, murder or, if one is religious, some terrible form of blasphemy.
Example Of Pure O :
Indeed, I once saw a documentary about a man who suffered from this condition. He was obsessed by the idea that he might commit murder whilst sleepwalking at night and took his concern so seriously that, as a result, he never went to sleep without first chaining his ankle, complete with padlock, to the metal bed-frame each night (however, the hypothetical question of whether he could, in theory, retrieve the key, open the padlock and then commit murder – all in his sleep – was left unaddressed!).
In any event, he was no more likely to commit murder in his sleep than anybody else – his concern was what could be termed a ‘delusional concern’ and solely a symptom of his psychiatric condition as opposed to being based on any real, objective risk.
How Does Pure O Differ From Main Forms Of OCD?
Pure O differs from the main forms of OCD in so far as the rituals one feels compelled to carry out are mental, internal, and, therefore, hidden from others and (unless one chooses to confide
in others about them) secret; this contrasts with the rituals carried out by those suffering from the main forms of OCD that tend to be observable by others (such as compulsive hand-washing or checking doors, windows, etc are locked and secure).
Statistics Relating To Pure O :
The onset of Pure O tends to be between the ages of approximately 13 years of age and 25 years of age. It has been estimated that it affects about one percent of individuals. However, this could be an underestimate as it is probable that many individuals don’t realize that they have the disorder or do not wish others to know about it so keep it secret and never seek professional help.
TREATMENT FOR OCD
WHAT TREATMENTS FOR OCD ARE NORMALLY GIVEN?
Experts in the field of the treatment of OCD generally recommend cognitive-behavioral therapy (CBT) which is made even more effective if it is combined with medication – usually, the medication will be an anti-depressant, although sometimes a benzodiazepine may be used.
Generally speaking, the anti-depressant is a long-term treatment, eg given for perhaps a minimum of a year, and up to a whole lifetime, even if symptoms significantly improve (this is done in order to minimize the chances of a relapse occurring).
On the other hand, if the individual with OCD is prescribed a benzodiazepam, this will generally only be taken over a short period of time (eg a period when the symptoms are very acute) in order to minimize the risk of the individual with OCD becoming physically and/or psychologically dependent upon them (as they are addictive).
HOW EFFECTIVE IS TREATMENT?
If studies on the effectiveness of anti-depressants for the treatment of OCD are looked at as a whole, on average individuals with OCD who undergo such treatment significantly improve around about 45% of the time. Whilst any improvement is obviously extremely desirable, in general the improvements individuals make by taking anti-depressant medication are not great enough to eliminate the need for other treatments being given alongside.
As has already been referred to, cognitive-behavioural therapy (CBT) is usually the type of therapy to be used alongside medication – in fact, it is a specific type of CBT which is known as EXPOSURE WITH RESPONSE PREVENTION (which I’ll henceforth refer to as EWRP). As has also been mentioned, if symptoms are extremely severe then benzodiazepine may be prescribed over the short term before the EWRP can take place.
WHAT DOES EWRP ACTUALLY ENTAIL?
We have already looked at how sufferers of OCD have obsessive thoughts which cause them distress. What EWRP is designed to do is to help the individual TOLERATE SUCH DISTRESS.
For, example, one common way in which OCD manifests itself is by making the sufferer inordinately and irrationally fearful of germs.
Therefore, s/he may constantly be acutely anxious that his/her hands are ‘dirty’ and that this is potentially ‘highly dangerous’ – this, in turn. leads to constant compulsions to wash their hands in order to relieve their distressing and acute anxiety.
However, the sense of relief is extremely ephemeral and the compulsion returns, perhaps leading the afflicted individual to wash his/her hands 100 times a day.
In the above example, the approach EWRP takes is to help the person tolerate the distress that his/her perception of having ‘dirty’ hands causes him/her by encouraging him/her not to wash them for a given period of time.
As the person becomes better and more used to the anxiety caused by not washing them, the period of time can be gradually increased. The idea is that the person will become desensitized to the anxiety associated with unwashed hands.
On top of this, CBT can be used to help the individual challenge irrational thoughts which are connected to his/her OCD. For example, in the case described above, the individual could be helped to challenge thoughts such as ‘having any dirt on my hands is highly dangerous’ and to understand that the thought is an enormous exaggeration of any objective danger.
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David Hosier BSc Hons; MSc; PGDE(FAHE).