Tuesday, March 27, 2012

Core Beliefs in Obsessive Compulsive Disorder


An unusual obsession of “adverse remarks”
Ms. G. is a student of information technology aspiring to acquire a degree in it. But she couldn’t continue her studies because of her psychological problems. She described her mental problem hesitantly. She admitted that her problem, she feels, is silly. Hence she felt the hesitancy in presenting it to me. She was not sure that they are actually mental problems at all, because they are just thoughts intruding into her mind.
Whenever she saw a person, stranger or friend, some adverse remark about that person intruded into her mind against her will. I asked her to give some examples of such ‘adverse remarks’ and she reluctantly obliged. Following are some of the examples she gave:
This man is a bad person.
That woman is an over smart.
This boy is naughty.
That girl is ugly looking.
The thoughts are not the real problem. Whenever such an unacceptable thought intruded into her mind she felt guilty and experienced ‘tension’ out of this guilt feeling. Worsening her condition she feels a compulsion to apologize to the person for having such an unacceptable thought in her mind.  If she didn’t apologize to the person, the tension and guilt feeling doubles. There came a stage of her mental problem at she stopped going to her classes. A doctor related to he advised her to seek help from a psychiatrist.
A cursory psychological examination revealed that she was suffering from Obsessive Compulsive Disorder (OCD). Since her OCD has advanced to a severe state I decided to treat her with Selective Serotonin Re-uptake Inhibitor (SSRI) drug and cognitive behaviour therapy.
Prevalence of the disorder
Studies show that approximately 90% of people have intrusive thoughts which may not be unacceptable to the individual. People with OCD take these thoughts to a disruptive and unhealthy level. Their intrusive thoughts or obsessions force them into a series of compulsive behaviours as a kind of defensive mechanism against the obsessions. OCD is a pattern of ritualized behaviour used to cope with distressing situations.
Ms. G. developed a ritual of apologizing to the persons whom she thought badly about in her mind. A particular ritual may present relief to the obsessive individual, but eventually, the behaviour becomes distressing to the sufferer of OCD, because it disrupts everyday interactions in life.  
What are obsession?
Obsessions come to one’s mind as repeated images, impulses, or thoughts against the will of the person. These make the obsessive person feel negative emotions, the most common being anxiety, stress, revulsion or apprehension. Inability to “stop” these impulses and thoughts make the OCD person feel out of control. Though the person realizes on some level their obsession with these thoughts is irrational, they feel the need to develop mechanisms to cope with their negative emotions. These mechanisms tend to become compulsive behaviour, which is a kind of ritual which offers short term relief to the sufferer.
Possession by devils
In the Middle Ages these intrusive thoughts and compulsive rituals were thought to be due to possession of devils and evil spirits. In the Malleus Malleficarum (Hammer of the Witches) written by the two Dominican inquisitors, Heinrich Kramer and James Sprenger, there is descriptions of a 15th century patient’s intrusive thoughts:
“When he passed any church, and genuflected in honour of the Glorious Virgin, the devil made him thrust his tongue far out of his mouth; and when he was asked whether he could not restrain himself from doing  this, he answered: ‘I cannot help myself at all, for so he uses all my limbs and organs, my neck, my tongue, and my lungs, whenever he pleases, causing to speak or to cry out; and I hear the words as they were spoken  by myself, but I am altogether unable to restrain them; and when I try to engage in prayer he attacks me more violently, thrusting out my tongue.”
The inquisitors subjected the person severe torture to exorcise the devil in him and the innocent patient of Obsessive Compulsive Disorder died.
Behavioral part of treatment
The treatment technique that works best for OCD is the Exposure and Response Prevention (ER&P). The ER&P encourages patients to expose themselves to their obsessions and try to stop themselves from compulsive rituals to get rid of anxiety and tension that they are feeling. People with OCD usually avoid situations which cause intrusion of unacceptable thoughts. For example a person suffering from intrusion of blasphemous thoughts in religious places avoids church, temple or mosque. Ms. G. avoided going out and she discontinued going to classes. He/she should be advised not to avoid places of worship even if blasphemous thoughts cause mental tension. Repeated exposure to such situations may reduce anxiety in due course and obsessions may subside. The ER & P is the behavioural part of the Cognitive Behavioural Therapy (CBT)
Find out core beliefs
            The cognitive aspect of CBT is recognition of the core beliefs which causes intrusion of the unacceptable thoughts and the accompanying negative emotions such as anxiety, fear and depression. These core beliefs about the self and the world shape everything we do, including Exposure Therapy for OCD. The OCD patients entertain the following core beliefs:

  1. I must be perfect or I'm a failure and therefore worthless.
  2. I must do everything right on the very first try.
  3. I must never make a mistake.

These beliefs are deep-seated in the mind are on auto-pilot. They guide the actions of the individual even before he/she realizes it. Obsessions and the rituals are motivated by these beliefs.
Another psychological aspect of obsession is the "Feared Consequences," thoughts of which compel the patient do the rituals to avoid unacceptable thoughts. Following are usual thoughts of “Feared Consequences.”
If I make a mistake, this will prove I am worthless, and I will have no hope of peace or joy in my life.
I will implode from the pressure of my defectiveness.
I will go crazy from the anxiety caused by my defectiveness.
There are a number of common obsessions:
  • Among the most frequently reported is the fear of contamination by germs, dirt, chemicals, or diseases. People with this obsession are often overwhelmed with thoughts of harming themselves or others, so they try to avoid coming into contact with certain surfaces, contaminated objects, dirt, or bacteria. In response to this fear, these people perform compulsions such as frequently washing their hands, changing their clothes, and avoiding dirty objects like doorknobs, shoes, and newspapers.
  • Repetitious uncertainty is another common obsession. This can include doubts about whether or not the person turned off the stove, made a mistake at work, or hit someone while driving. This type of obsession leads to compulsions that are extremely time-consuming. The person is rarely satisfied with the safety or perfection of his or her actions and thus must check and recheck his or her own behaviors. Examples include returning home multiple times to make sure the oven is turned off and repeatedly turning the car around to make sure the person really didn't hit someone in the road.
  • Obsessions of perfection are thoughts that require the person to arrange objects perfectly or to perform tasks in a rigid, systematic fashion. Often, people with this compulsion can’t complete a task if they can’t perform every step of that task in a specific order.
  • Obsessions about causing harm to others lead the person to think about hurting other people, including strangers. This type of obsession may cause the person to perform reassurance behaviors, which are actions they take to make sure that other people are safe, like continuously calling someone on the phone.
  • Sexual obsessions often involve intrusive pornographic thoughts. This type of disturbing imagery may cause people to play mental games to distract themselves, like drawing pictures in their imaginations.
  • Religious obsessions tend to focus on the fear that the person isn’t doing what is morally right or the thought that he or she is going to be punished by God. Religious obsessions can also include uncontrollable, blasphemous thoughts in which the person curses God. In these cases, the person might perform a praying ritual or draw some type of religious imagery in a notebook.
  • Other obsessions include urges to do things that seem aggressive or very much out of the ordinary, like screaming at others for no reason. Afterward, the person might feel compelled to do something to relieve feelings of guilt or shame.

These are just a few examples of different types of obsessions. In all of these cases, the worries are highly unusual. They are not obsessional worries about common, daily occurrences, like paying the bills or getting to work on time. For each one of these obsessions, there are numerous types of compulsions, not just the ones listed here. In fact, a person’s obsessions and compulsions may not even be related to each other in any obvious way. A person may do anything after the intrusive thought to relieve him or her of anxiety. For example, a woman with a fear of contamination might obtain just as much relief from singing a song each time she feels dirty as she does from washing her hands. However, in all cases, the obsession and the action that follows it become habitual, time-consuming, and disturbing to the person who experiences them.

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