June 16, 2024
Mental health
One of the more difficult symptoms of OCD that my patients deal with is the presence of mental compulsions. Compulsions can be anything that a person does to alleviate anxiety, dread, or other unpleasant feelings. There are many types, but there are two main categories of compulsions: mental and behavioral. Behavioral compulsions, such as constantly checking the door locks or washing your hands too often, can be observe. Mental compulsions are a mental phenomenon that occurs in mind. Mental compulsions include:
  • Silently counting or using “lucky words.”
  • Rewinding past events and conversations.
  • Analyzing why someone has a particular obsession.
Let’s look at Harm OCD as an example. Harm OCD is when a person has intrusive thoughts or obsessions that put them at risk of harming/abusing others through their negligence, deliberate actions, or both. Because these thoughts are morally repulsive and totally out of character, OCD can be very challenging for patients. Harm OCD can include the fear of pushing someone to death, sexual abuse, and accidentally poisoning someone. One of my patients believes she will randomly slap anyone if she has an intrusive thought or a tingling sensation. She learned to accept that she could not avoid situations that would trigger her obsession. She had to be open to her focus and not succumb to compulsions. Exposure and Response Prevention- ERP is the standard gold treatment for OCD. She wanted to be close to people, not create barriers between her and those she thought might be affected. She had to let go of holding her hands together and allow her hands to touch her sides. She had to let her hands feel tingly and not worry about whether it would cause her to slap another person. She stood close to people on the subway, at work, and in her sessions with me. She was told not to trigger her obsession and to refrain from compulsions. She completed seven weeks of weekly psychotherapy and began practicing ERP daily. She felt much better after her OCD subsided, and she could live an everyday life. She returned to the hospital a year later with a resurgence in her symptoms. She was now afraid of hitting people and had thoughts about her boyfriend’s death. She was obsessed with harming children and feared seeing her friends’ babies, fearing she would drown them. Insistent studies suggested that she might have schizophrenia but not OCD. After the break in treatment, my first encounter with her was when I asked her about her intrusive thoughts. She explained that she was trying to be triggered, not to hold her hands together when she felt the urge to hit. These were all excellent exposures. However, I was curious to see her thoughts immediately after having an intrusive idea about hurting someone or feeling crazy. After having these obsessions, she felt distraught. She then asked herself why. She thought, “If I’m such an excellent person, why am I having these thoughts?” Then she went on a rabbit trail of unanswered questions. She She believed her obsessions were natural, and she wanted to hurt someone. Her OCD roared back at her with its demands that it be sure that she would never cause harm to anyone. She was consumed by “What If” statements: “What happens if my control is lost and I act out my obsessions?” She might answer these questions and tell herself she will go to prison, her boyfriend will divorce her, she won’t be able to work in her field again, and she won’t have children. It would then reassure herself that this wouldn’t happen. Her OCD then asked her, “Are you certain?” She went around and around in her head. She analyzed and analyzed, but she couldn’t find any answers. They was engaging in compulsive mental behavior to lessen her terror at the thought of hurting someone. She felt a momentary release from her OCD through mental compulsions. But, her OCD got worse because she now has no other reason for having these thoughts. After identifying her mental compulsions of analyzing and asking “What if?” questions, we discussed ways to stop them. Although there are many ways to accomplish this, mental compulsions can be difficult to overcome because they occur immediately after the initial obsession. One of the tenets of ERP is to allow the focus to “hang out” in the person’s mind, to fully experience the anxiety/dread/anguish caused by the obsession, and do nothing about it. It’s hard to stop addiction from becoming a compulsion. It is challenging to distinguish focus from compulsions. This has led to the false belief that OCD sufferers may only experience obsessions, not compulsions. These people are incorrectly called “Pure O.” The truth is that they primarily engage in mental compulsive behaviors after they have experienced the obsession. Understanding the difference between obsessions and mental compulsions is easy when you consider that both obsessions and compulsions can thought of as thoughts. However, compulsions can voluntary and are design to eliminate the unpleasant feelings caused by the obsession. Obsessions can be voluntary. Obsessions are not something you can change, but they can controlled. This is an important distinction. My patient believed she was suffering from anxiety due to the obsession. However, she was avoiding the obsession through mental compulsions. While asking unanswered questions may temporarily relieve, constant analysis can lead to anxiety because there is no answer. The patient had to return to the obsession to recover mentally. People with Harm OCD find this particularly frightening. These people often imagine themselves committing atrocious acts against innocent people. My patient was afraid of these obsessions. She couldn’t imagine her boyfriend being stabbe or drown. To recover, she had to be able to accept these images and their accompanying horrifying feelings and not run from them. The patient could recognize the dangerous thoughts and ideas after being expose without resorting to any thinking or behavioral compulsions. These obsessions were just random noises that the brain generated, and she no longer needed to analyze them.

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