How To Treat Pure Obsessions?

Obsessive compulsive disorder is a diagnostic category reserved for those cases in which the patient manifests obsessions and compulsions. In some less prevalent cases, these patients may come to the consultation with symptoms based solely on obsessions.

It is what is known as pure OCD or pure obsessions. Obsessions can be defined as recurring and persistent thoughts, impulses or images that are experienced, at some point during the disorder, as intrusive or unwanted and that in most subjects cause significant anxiety or discomfort.

Compulsions usually bring very short-term relief. Anxiety or tension felt from obsessions is negatively reinforced by compulsive behavior.

This compulsion causes the problem to persist and it ends up becoming chronic  because the patient learns that it is the only way they have to get rid of the anxiety and unpleasant thoughts that inhabit their mind.

Compulsions are usually not realistically connected to the fact that what is feared does not happen, or they are clearly excessive. For example, a patient may believe that if she slaps her hands three times when leaving and entering the door of her house, then her husband will not be in a traffic accident on the way to work.

Patients who do not manifest this type of symptomatology, namely, they do not resort to compulsions to alleviate their discomfort, they are more complex. Treatment for pure obsessions is more difficult, but psychological techniques are now available to deal with it.

The key is habituation

The fact that obsessions are reinforced in a negative way when practicing compulsion leads to non-habituation to anxiety or fear that they generate.

Therefore, obsessions are fed; and by feeding them progressively, they get fatter. Similarly, in pure obsessive disorders, treatment is based on habituation and for this to occur it is essential to carry out an exposure to one’s own obsessions.

Exposure is often aversive to patients. Response-preventative exposure can lead to significant rejection and even discontinuation of treatment. This is one of its disadvantages; However, to date, the empirical evidence shows us that they are the treatments that report the most therapeutic success in the majority of patients who manage to complete them.

The objective, finally, is for the person to expose themselves to their thoughts or images in such a way that, voluntarily, they must take them out and “look them in the eye”. Habituation training emerges from the research of Salkowskis and Westbrock.

It is usually carried out on an audiotape in which the patient records their pure obsessions and listens to them repeatedly until they become accustomed to them. The predictability of the stimuli to which the subject is exposed is the key factor in treatment. By means of the recording, the patient can predict what he is going to hear, contrary to what happens with pure obsessions, which are not unpredictable.

In addition to the audio recording, other strategies can be used to present the thoughts in a predictable way : deliberately evoking them by narrating them in session or putting them in writing and rereading them until the anxiety subsides.

It is necessary to explain in detail to the patient how anxiety works and how habituation follows a curve in which it first increases, but at a point it begins to decline. Psychoeducation facilitates adherence to treatment and fosters the therapeutic relationship.

The anxiety curve

The characteristic curve of anxiety is shaped like an “inverted U”. As we have already noted, when a person is exposed to their fears (whether through pictures, live, or in the case of pure OCD by recording or writing) they experience a substantial increase in anxiety.

This moment is key because the patient thinks he is worse and he is right, he feels much more anxious. But that nasty climb is finite. Physiologically and inevitably, the rise in anxiety has a limit.

When this discomfort reaches the maximum point and if the patient does not perform any ritual, safety behavior or any avoidance of any other kind, the anxiety will begin to descend progressively. Why is this happening? First, on an emotional level, anxiety, or any other emotion, increases linearly. It is not the characteristic pattern. There has been no case in which the emotion rises and rises until it kills anyone. Not much less.

On the other hand, the simple fact of becoming aware that our cognitions are skewed or unrealistic, allows us to modify them for others much more moderate, with which anxiety begins to lose those anchors that it used to grow before.

Ultimately, the fundamental thing is to prevent the patient who is going to expose himself to his obsessions or any other stimulus that causes anxiety from knowing that staying and persisting is the key to success. In fact, short exposures can produce an iatrogenic effect whereby the patient not only does not overcome his fear, but increases it.