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Author: Kristy Cobillas, LPC
We have all heard someone claim that they have Obsessive Compulsive Disorder because of their proclivity toward keeping things neat and organized. Many a joke has been made regarding having “OCD friends” over so that they can clean the house. Those truly suffering with the disorder could only wish it were simply a matter of being particular or neat; unfortunately, that is not the case.
OCD is an insidious, lifelong, painful, neuropsychobiological disorder in which the sufferer is besieged by intense intrusive thoughts and obsessive ideas. These uncomfortable thoughts and ideas are warded off by repetitive compensatory compulsive behaviors.
Obsessive Compulsive Disorder (OCD) could be thought of as a death by “1000 what ifs.”
What if... I'm contaminated?
What if... Someone trips over this item that I saw laying on the ground…. will it be my fault? (responsibility OCD)
What if… I am really a child molester?
What if ... I had an affair and forgot?
What if... I throw this out and I need this later? ( Hoarding)
What if...I am turning my enjoyment of watching baseball into an idol?” (scrupulosity)
What if... I'm evil?
What if... I really want my parents to die?
These are all questions that an OCD sufferer might ask.
It is common for everyone to have a fleeting “what if” thought. For example, one might have the thought “what if my parents died?” The thought would be there momentarily, perhaps causing a little bit of distress, but would easily fade into the background, especially if there is no evidence that one's parent’s lives are in peril. However, for the OCD sufferer, this “what if” thought would be followed up by repetitive questioning of the parent's health, driving by the parent’s house a couple times a day to make sure they're still alive, possibly even making pleas to the parents to not fly or drive in their car. The continuous obsessive thoughts and checking behaviors would not only be distressing for the client, but also for the family.
What the neurotypical brain views as not a “big deal”, becomes exponentially exaggerated in the mind of one who has OCD. For example, most people will think nothing of going 61 on the highway, but for the person who suffers from scrupulosity OCD, the thought that they are “sinning against God” by speeding will weigh heavily on them, and they will slow down. (Which only reinforces the ocd loop.) They will spend their existence making sure they are doing everything possible to be “perfect” and will come to the sad realization that it is impossible. The hyper-focus on perfection will lead to a tormented existence as neurologically, there are associated neural pathways being built with the attentiveness to imperfection. The sensation the client experiences feels as if there are tentacles reaching out of the brain grasping any slight indiscretion. This creates a heightened awareness and paranoia that can be overwhelming for the sufferer. The anxiety for the OCD sufferer is immense and there is no sense of peace until the issue of the moment is thoroughly examined, compulsed upon and/or “feels right.” The sufferer will rationalize, reason, fight with, research, question, seek assurance, and try to fight their way to a place of logic…. But there is one huge issue….
OCD does not listen to reason and it does not accept facts. Little traction is gained by therapeutic techniques such as socratic questioning or argumentation. Most who suffer from OCD already know it’s irrational. They cannot “just stop it” and they are far more tormented by their OCD than those who find their behaviors annoying and inconvenient.
Is there hope for recovery?
The first step towards relief starts with a good understanding of what is actually happening in the brain. This is so very important because it helps the client to understand that it's not about the contamination, the sinning against God, whether or not they ran over someone on the highway and didn't know it. (all of which are common OCD ideas that the sufferer will NEVER know the answers to...so they keep cycling through the brain.)
The truth is, there are neurobiological anomalies in the OCD brain. Understanding this will reframe what is happening and will give traction for what needs to be done.
So, why is this happening?
Utilizing Functional MRIs as well as SPECT scans, researchers have produced a wealth of information regarding neurological hyperactivity (rapid firing of neurons) in a specific loop in the brain for those who suffer with OCD. In the non-OCD brain, thoughts are produced in the orbital frontal cortex, and travel to the thalamus, a central station which sends information to the other cortical regions, including the basal ganglia.
BASAL GANGLIA- This is where the first mishap takes place. Through our senses, our brain takes in all kinds of information. This information travels to the basal ganglia, which is a region of the brain that is supposed to filter out extraneous thought. In the neurotypical brain, the Basal Ganglia is like a fine mesh filter. In the OCD brain, it is like Swiss cheese; all all sorts of information flows through. This flood of information is then sent to the AMYGDALA,which plays a part in processing emotion and motivation. There is an emotional reaction to all this information. Things are interpreted as dangerous that are really notdangerous, in fact, they should not have come into the consciousness at all! The result is that every thought appears to be of utter importance and rumination takes place. Levels of serotonin drop, which impact the ability to regulate mood, aggression and impulse. Finally, the information is sent to the CINGULATE GYRUS, a region of the brain that is essential in regulation of emotion and pain, as well as the task of transitioning from one thought or activity to another. For the OCD sufferer, the cingulate gyrus is hyperactive, and the thought gets “resent” through the loop, to be thought through again. It's at this moment when most OCD sufferers will say “it doesn’t feel safe to let it go.” As one can imagine, the neurological activity in the brain is immense. Pet scans have shown that the firing in the brain with regards to this neurological loop is profound.
That is good information, but what do we DO about it?
First, giving the client the context for what is happening is essential, as it lessens the emotional charge and stigma of OCD. Next, in order to explore what keeps the client immersed in the OCD loop, a functional analysis will be necessary before treatment begins. Appropriate treatment for OCD will include Exposure and Response prevention (ERP), as it is the gold standard for reduction of intrusive thoughts and repetitive behaviors associated with the disorder. In addition, Acceptance and Commitment Therapy techniques, mindfulness, psychoeducation regarding how to identify an OCD thought (as they ALL seem SO REAL), bibliotherapy, and journaling, are all extremely effective with the behavioral and cognitive aspects of the disorder. In other words, a multifaceted approach will be necessary.
What will be the results if this protocol is followed?
Unfortunately, OCD never completely goes away. It can become very quiet and sit in the background of the mind, only to resurface during times of stress or difficulty. Sometimes the thoughts will be at a far distance and sometimes they will come flying in and overtake. Sometimes they will even disappear. Becoming skilled at utilizing the tools from a holistic therapeutic approach, will help the OCD client to tame the severity and manage the symptoms of OCD.
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