Obsessive Compulsive
Symptoms
Lesson Goals
• Review a diagnosis that used to be considered central in Anxiety
Disorders
• Has it’s own classification (incudes: hoarding and manias)
• But it is a different way of responding to anxiety
• Is a common and often praised trait of our time
• Review some experiential and personal accounts (videos)
• Take a look at the neurobiological correlates and mechanisms related
to OCD
Why is OCD more typical in our culture?
Thinking and doing
• “People with personalities organized around thinking and doing
abound in Western societies. The idealization of reason and the faith
in progress through human action that were hallmarks of
Enlightenment thinking still permeate our collective
psychology(…)esteem scientific rationality and “can-do” pragmatism
above most other attributes. ”
• “The “workaholic” and the “Type A personality” are popularly
acknowledged variations on the obsessive–compulsive theme.”
• Excerpt From: McWilliams, Nancy. “Psychoanalytic Diagnosis, Second Edition.”
• Obsessed with thinking and/or actively compulsory
• They will seek treatment to rid themselves of intrusive obsessive thoughts, or the
compulsion to repeat (when ego-dystonic, if not, they are a personality organization)
• “As symptoms, obsessions (persistent, unwanted thoughts) and compulsions
(persistent, unwanted actions) can occur in anyone”
• “They are generally dependable and reliable and have high standards and ethical
values. They are practical, precise, and scrupulous in their moral requirements.
Under conditions of stress or extreme demands, these personality characteristics
may congeal into symptomatic behavior that will then be ritualized. (p. 10)”
Selzman
• “Living machines”
Close to what Bollas described as:
Normotic
• “It is truly reassuring to become part of the machinery of production. He likes being
part of an institution because it enables him to be identified with the life or existence of
the impersonal…The normotic takes refuge in material objects. He is possessed of an
urge to define contentedness through the acquisition of objects, and he measures
human worth by means of collections of acquired objects.” (138).
• This type of person has succeeded in neutralizing the subjective element of their
personality, and their minds are characterized less by the psychic (symbolization through
representation of feelings, sensations and inter-subjective perceptions) than by the
objective. „This mentality,” Bollas says, „is not destined to represent the object, but
rather to be the „echo” of material objects, to be an object of commodity in the world
of human production.”
• someone abnormally normal: too stable, secure, calm and socially extroverted. Since
they are fundamentally uninterested in the subjective life, they are inclined to reflect on
the material characteristics of objects, on their material reality, or on „facts” regarding
material phenomena.
Still present
• “In old-fashioned obsessive–compulsive-breeding families, control
may be expressed in moralized, guilt-inducing terms, as in “I’m
disappointed that you were not responsible enough to have fed your
dog on time,” or “I expect more cooperative behavior from a big girl
like you,” or “How would you like it if somebody treated you that
way?” Moralization is actively modeled. Parents explain their own
actions on the basis of what is right (“I don’t enjoy punishing you, but
it’s for your own good”). Productive behavior is associated with
virtue, as in the “salvation through work” theology of Calvinism.
Self-control and deferral of gratification are idealized.”
Drive and affect
• “Freud’s (1909, 1913, 1917b, 1918) emphasis on fixation at the anal
phase of development (roughly 18 months to 3 years), particularly on
aggressive urges”
• “the features that typically hang together in people with obsessive–
compulsive personalities—cleanliness, stubbornness, concerns with
punctuality, tendencies toward withholding—are the salient issues in
a toilet-training scenario. ”
• The anal stage
• “ The experience of being controlled, judged, and required to perform
on schedule creates angry feelings and aggressive fantasies, often
about defecation, that the child eventually feels as a bad, sadistic,
dirty, shameful part of the self.
• The need to feel in control, punctual, clean, and reasonable, rather than
out of control, erratic, messy, and caught up in emotions like anger and
shame, becomes important to the maintenance of identity and self-
esteem.
• The kind of harsh, all-or-nothing superego created by these kinds of
experiences manifests itself in a rigid ethical sensibility that Ferenczi
(1925) wryly called “sphincter morality.”
• Being controlled by the other leads to needing to control oneself:
behavior-emotions.
Abnormal?
• It is also a normal part of development and thinking
• Thought is designed to make sense (the stories we make about our
day out universe)
• Need to routines, and predictability
• Things must be completed, finished, perfect, neat (Zeigarnik effect)
• If not: anxiety
• See gif
• “ overprotective parents get in the way of a young child’s taking the
small risks that are necessary to develop a sense of the boundary of
self, and accounts for the omnipotent, magical thinking found in
obsessive and compulsive people in terms of the lack of this
boundary.”
• Extreme in the case of psychotic obsessions (I am God), but present in
OCD (If I do this, everything will be ok, so I MUST do this), to “normal”
thought:
• “Once you make a decision, the universe conspires to make it happen.”
• The fact that nothing happens, feeds the magical thought
• Therapeutic difficulty
• Use words to conceal feelings, not to express them.
• Most therapists can recall instances of asking such a client how he or she felt about something
and getting back what he or she thought
• Commonly use isolation as principal defense mechanism for obsession ;
undoing for compulsion
• But they use the typical “advanced” or “mature” mechanisms: rationalization,
intellectualization; reactive formation
• (undoing: “One of my patients, a married oncologist who knew very well that AIDS is
not easily transmitted by mouth-to-mouth contact, felt helplessly compelled to get
tested repeatedly for HIV antibodies after she had kissed a man with whom she was
tempted to have an affair.”) Guilt (Un)Reasonable obsession.
• (reaction formation: “People who are strongly preoccupied with being upright and
responsible may be struggling against more powerful temptations toward self-
indulgence”) Patient who was very worried about her husband’s well-being (she
ddiliked and was angry at him)
• Example of the over-logical thinking as defense mechanism:
• “Not every human activity should be approached from the standpoint of rational analysis
and problem solving. Compulsions:
• “the disparity between what one feels impelled to do and what is reasonable
to do can be glaring. Compulsive activities may be harmful or beneficial; what
makes them compulsive is not their destructiveness but their drivenness.”
• THEY MUST BE DONE! They are unavoidable.
In treatment
• They may appear as perfect patients:
• Follow all rules, bring up thoughts as requested, require structure and
recommendations. May even take notes.
• They make therapy their new compulsion.
• Like the “devoted but demanding and judgmental parent, and to be consciously
compliant and unconsciously oppositional. Despite all their dutiful cooperation, they
convey an undertone of irritability and criticism. When a therapist comments on
possible negative feelings, they are usually denied. ”
• CT:
• “annoyed impatience, with wishes to shake them, to get them to be open about
ordinary feelings, to give them a verbal enema”.
• “Their combination of excessive conscious submission and powerful unconscious
defiance can be maddening”
• “Doubts about whether anything is being accomplished in therapy are typical ”
Main issue: who controls and how much
• “Asking the patient’s direction on how much the therapist should speak, like
other respectful inquiries about what is helpful, may resolve the therapist’s
problem while supporting the client’s sense of agency, human equality, and
realistic control.”
• “The second important feature of good work with people in this diagnostic
group, especially the more obsessional ones, is the avoidance of
intellectualization. ”
• How to not only make it about cognitions?
• Ask about affect
• Increase insight into their need to organize and control
• Discuss the relational (don’t allow them to “clean” the field and ask about their feelings IN therapy):
“can be exasperating that the therapy process does not work as fast as we would both want it to. Don’t
be surprised if you find yourself having resentful thoughts about coming here or about me. If you were
to notice you were feeling dissatisfied with our work, would anything get in the way of your telling me
that?”
Neurological correlates
• lesions in the cortico-striato- thalamic
circuit, parietal and temporal cortex,
cerebellum and brainstem may induce
compulsivity. (inhibitory function
diminished impulsivity of compulsions
and obsessions)
• abnormal activity of the frontal-subcortical
circuit might cause executive dysfunction
and secondary nonverbal disturbances, and
result in OC symptoms.
• sustained OC symptoms enhance abnormal
activity of the neurocircuits and
neuropsychological disturbance, which resulted
in a vicious cycle among brain, cognition, and
clinical symptoms.
Also…
• Neurological disorders of the basal ganglia (reward system), such as
tic disorder, Tourette disorder, Sydenham’s chorea, and Huntington’s
disease, have comorbid OCD symptoms.
• Basal ganglia modulate higher cognitive functions, such as behavior
planning, attention, social behavior, and decision- making, as well as
modulate motor function by connecting with the cerebral motor
cortex. Impairment of higher cognition in basal ganglia might cause
the pathophysiology of OCD.
Psychotherapy
Psychotherapy will alleviate
compulsive behavior and
cognition by acting on cortical
regions, including the DLPFC,
and result in amelioration of the
obsession.
On the other hand, SSRI and
neuroleptics will decrease
obsessions and emotions by
acting on limbic and basal
ganglia
Different symptoms
Integrative view
• Psychodynamic therapy may work by being able to process affect and
unconscious fears (anger, guilt) and assigning them meaning through
interpretation, thereby enhancing the ability of the psyche.
• CBT techniques allow for an habituation towards anxiety and reducing
the maintain behaviors as a result of repetition of situations in which
compulsions are no longer effected and no catastrophe occurs.
• In both cases, there may be an increase in cortical processing and
affective modulation(through executive functioning).
• Thought processing --> decrease in fear through interpretation
• Habituation decrease in compulsions through repetition and response
inhibition
