Essentially, compulsions are actions or thoughts that are repetitively performed in an attempt to reduce or eliminate anxiety or distress triggered by obsessions. A compulsion may be an attempt to prevent obsessions from coming to mind (perhaps by repeatedly praying for such thoughts to be prevented, or repeating a phrase intended to block such thoughts), or it may be an attempt to prevent some feared outcome associated with the obsession (such as calling a friend to warn them to be careful after having an image come to mind of that friend being in an accident).
In the beginning stages of the development of Obsessive Compulsive Disorder compulsions provide fast relief from the anxiety or distress created by intrusive thoughts – uninvited, upsetting thoughts that can pop into our minds unexpectedly.
During the peak of AIDS anxiety in the ’80s and early ’90s, for example, many people experienced intrusive thoughts of possibly having contracted AIDS from public toilets. Due to a lack of accurate information about HIV and AIDS during that time, these thoughts would be often accompanied by catastrophic predictions of one’s own death and the infection and death of loved ones and others. The 1987 image of the grim reaper used by the Australian Department of Health stuck in the minds of many. It is logical enough that if a man thought he might have been exposed to the virus after using a public toilet he would take some action to eliminate the risk of contracting the disease: perhaps by washing his hands twice with soap; perhaps by more drastic means of disinfection.
Taking such an action would typically eliminate some, or all, of the anxiety produced by the original thought that there was a risk of contracting AIDS. This produces a domino effect:
- the reduction of anxiety is negatively reinforcing – it “rewards” the additional handwashing behaviour by removing an unpleasant stimulus (anxiety);
- because the additional handwashing was reinforced by reduced anxiety, it is more likely handwashing will be repeated if the worry reoccurs;
- by washing his hands twice he strengthens his perceptions that there was a risk to begin with – we will always adjust our beliefs to make sense of our behaviour and in this instance he can’t make sense of washing his hands a second time unless he reinforces to himself that the risk of contracting AIDS was real (he may see the probability of infection as minute, but the implications of infection sufficient to justify the small additional effort of washing his hands again);
- the now heightened perception of risk and the action of handwashing taken to prevent harm together create a sense of needing to be vigilant to future risk of infection – increasing the likelihood that thoughts about possible infection with AIDS Will occur in the future.
The handwashing compulsion is as a critical component in this cycle that progressively increases the frequency of thoughts of having been exposed to AIDS and the anxiety associated with those thoughts. As handwashing becomes more problematic, other compulsions may be introduced as alternative ways of removing the anxiety associated with the obsessions of contamination. He may now ask people for reassurance that infection was not possible in a particular situation. He may seek reassurance by repeatedly having blood tests for HIV; he may repetively seek out facts about the virus and pathways of infection that would provide assurance that infection did not occur.
In order to treat OCD it is necessary to disrupt this cycle of obsessions and compulsions. The “common sense” approach often attempts to disrupt the cycle at the point of the obsessions: By “thinking about other things” or picturing a stop sign when obsessions come to mind. Unfortunately this just doesn’t work in practice. Such strategies paradoxically direct more attention towards the obsessions and tend to both increase anxiety and create frustration at one’s own inability to control one’s thoughts.
Treatment for OCD that has proven effective involves disrupting two points in the cycle: the mis-calculation of risk and responsibility, and the compulsive behaviour. Exposure and response prevention (ERP, a behavioural therapy that is one of the effective treatments for OCD) involves exposure to triggers coupled with inhibition of the compulsive responses. Additionally challenging thinking patterns that over-estimate risk and rsponsibility can improve treatment outcomes. Cognitive behavioural therapy for OCD should combine these two critical components.