Primarily obsessional obsessive compulsive disorder

"POCD" redirects here. For the other meaning of this acronym, see Postoperative Cognitive Dysfunction.

Primarily cognitive obsessive-compulsive disorder (also commonly called "primarily obsessional OCD", purely obsessional OCD, Pure-O, OCD without overt compulsions or with covert compulsions)[1] is a lesser-known form or manifestation of OCD. For people with primarily obsessional OCD, there are fewer observable compulsions, compared to those commonly seen with the typical form of OCD (checking, counting, hand-washing, etc.). While ritualizing and neutralizing behaviors do take place, they are mostly cognitive in nature, involving mental avoidance and excessive rumination.[2] Primarily obsessional OCD often takes the form of intrusive thoughts of a distressing or violent nature.

Common themes

Primarily obsessional OCD has been called "one of the most distressing and challenging forms of OCD."[3] People with this form of OCD have "distressing and unwanted thoughts pop into [their] head frequently", and the thoughts "typically center on a fear that you may do something totally uncharacteristic of yourself, something ...potentially fatal...to yourself or others."[4] The thoughts "quite likely, are of an aggressive or sexual nature."[5]

The nature and type of primarily obsessional OCD varies greatly, but the central theme for all sufferers is the emergence of a disturbing intrusive thought or question, an unwanted/inappropriate mental image, or a frightening impulse that causes the person extreme anxiety because it is antithetical to closely held religious beliefs, morals, or societal mores.[6] The fears associated with primarily obsessional OCD tend to be far more personal and terrifying for the sufferer than what the fears of someone with traditional OCD may be. Pure-O fears usually focus on self-devastating scenarios that the sufferer feels would ruin their life or the lives of those around them. An example of this difference could be that someone with traditional OCD is overly concerned or worried about security or cleanliness. While this is still distressing, it is not to the same level as someone with Pure-O, who may be terrified that they have undergone a radical change in their sexuality (i.e.: might be or might have changed into a pedophile), that they might be a murderer or that they might cause any form of harm to a loved one or an innocent person, or to themselves, or that they will go insane.

They will understand that these fears are unlikely or even impossible but the anxiety felt will make the obsession seem real and meaningful. While those without primarily obsessional OCD might instinctively respond to bizarre intrusive thoughts or impulses as insignificant and part of a normal variance in the human mind, someone with Pure-O will respond with profound alarm followed by an intense attempt to neutralize the thought or avoid having the thought again. The person begins to ask themselves constantly "Am I really capable of something like that?" or "Could that really happen?" or "Is that really me?" (even though they usually realize that their fear is irrational, which causes them further distress)[7] and puts tremendous effort into escaping or resolving the unwanted thought. They then end up in a vicious cycle of mentally searching for reassurance and trying to get a definitive answer.[2][8]

Common intrusive thoughts/obsessions include themes of:

Diagnosis and treatment

Those suffering from primarily obsessional OCD might appear normal and high-functioning, yet spend a great deal of time ruminating, trying to solve or answer any of the questions that cause them distress. Very often, Pure O sufferers are dealing with considerable guilt and anxiety. Ruminations may include trying to think about something 'in the right way' in an attempt to relieve this distress.[2][6]

For example, an intrusive thought "I could just kill Bill with this steak knife" is followed by a catastrophic misinterpretation of the thought, i.e. "How could I have such a thought? Deep down, I must be a psychopath."[18] This might lead a person to continually surf the Internet, reading numerous articles on defining psychopathy. This reassurance-seeking ritual will, ironically, provide no further clarification and could exacerbate the intensity of the search for the answer. There are numerous corresponding cognitive biases present, including thought-action fusion, over-importance of thoughts, and need for control over thoughts.[18]

Despite how real and imposing the intrusive thoughts may be to an individual, the sufferer will probably never carry out actions related to these thoughts, even if one believes themselves capable of doing so. One of the reasons for this is because the person in question will go to extreme lengths to avoid circumstances which could trigger their intrusive thoughts.

The disorder is particularly easy to miss by many well-trained clinicians, as it closely resembles markers of generalized anxiety disorder and does not include observable, compulsive behaviors. Clinical "success" is reached when the sufferer becomes indifferent to the need to answer the question. While many clinicians will mistakenly offer reassurance and try to help their patient achieve a definitive answer (an unfortunate consequence of therapists treating primarily obsessional OCD as generalized anxiety disorder), this method only contributes to the intensity or length of the patient's rumination, as the neuropathways of the OCD brain will predictably come up with creative ways to "trick" the person out of reassurance, negating any temporary relief and perpetuating the cycle of obsessing.

The most effective treatment for primarily obsessional OCD appears to be cognitive-behavioral therapy.[19] (more specifically exposure and response prevention (ERP)) as well as cognitive therapy (CT)[19][20] which may or may not be combined with the use of medication, such as SSRIs.[2][21][22] People suffering from OCD without overt compulsions are considered by some[23] researchers[24] more refractory towards ERP compared to other OCD sufferers[24] and therefore ERP can prove less successful than CT.[23]

ERP of Pure-O is theoretically based on the principles of classical conditioning and extinction. The spike often presents itself as a paramount question or disastrous scenario. A response that answers the spike in a way that leaves ambiguity is sometimes warranted. "If I don't remember what I had for breakfast yesterday my mother will die of cancer!" Using the antidote procedure, a cognitive response would be one in which the subject accepts this possibility and is willing to take the risk of his mother dying of cancer or the question recurring for eternity. No effort is expended in directly answering the question in an effort to find resolution. In another example, the spike would be, "Maybe I said something offensive to my boss yesterday." A recommended response would be, "Maybe I did. I'll live with the possibility and take the risk he'll fire me tomorrow." Using this procedure, it is imperative that the distinction be made between the therapeutic response and rumination. The therapeutic response does not seek to answer the question but to accept the uncertainty of the unsolved dilemma.[25]

Acceptance and commitment therapy (ACT) is a newer approach that also is used to treat purely obsessional OCD, as well as other mental disorders such as anxiety and clinical depression. Mindfulness-based stress reduction (MBSR) may also be helpful for breaking out of the ruminative thinking process.

Notes and references

  1. ↑ Hyman, Bruce and Troy DeFrene. Coping with OCD. 2008. New Harbinger Publications. Page 64.
  2. 1 2 3 4 Obsessive compulsive disorder By Frederick M. Toates, Olga Coschug-Toates, 2nd Edition 2000, Pages 111-128
  3. ↑ Hyman, Bruce and Troy DeFrene. Coping with OCD. 2008. New Harbinger Publications.
  4. ↑ Hyman, Bruce and Troy DeFrene. Coping with OCD. 2008. New Harbinger Publications.
  5. ↑ Hyman, Bruce and Troy DeFrene. Coping with OCD. 2008. New Harbinger Publications.
  6. 1 2 3 The OCD workbook By Bruce M. Hyman, Cherry Pedrick, Pages 16-23
  7. ↑ Obsessive compulsive disorder By Frederick M. Toates, Olga Coschug-Toates, 2nd Edition 2000, Pages 94-96
  8. ↑ The American Psychiatric Publishing textbook of psychiatry, By Robert E. Hales, Stuart C. Yudofsky, Glen O. Gabbard, American Psychiatric Publishing, includes Purely Obsessional OCD in its definition of O.C.D.
  9. ↑ http://www.ocdonline.com/articlephillipson2.php
  10. ↑ http://www.neuroticplanet.com/hocd.php
  11. 1 2 Obsessive-compulsive related disorders By Eric Hollander, pages 140-146
  12. ↑ Homosexuality Anxiety: A Misunderstood Form of OCD http://www.brainphysics.com/research/HOCD_Williams2008.pdf
  13. 1 2 3 Akhtar, S., Wig, NA, Verma, VK, Pershad, D., & Verma, SK A phenomenological analysis of symptoms in obsessive-compulsive neurosis. 1975
  14. 1 2 Use of factor analysis to detect potential phenotypes in obsessive-compulsive disorder, Psychiatry Research, Volume 128, Issue 3, Pages 273-280 D.Denys, F.de Geus, H.van Megen, H.Westenberg
  15. ↑ Doron, Guy; Derby, D.; Szepsenwol, O.; Talmor, D. (2012). "Flaws and All: Exploring Partner-Focused Obsessive-Compulsive Symptoms". Journal of Obsessive-Compulsive and Related Disorders. 1 (1): 234–243. doi:10.1016/j.jocrd.2012.05.004.
  16. ↑ Doron, Guy; Derby, D.; Szepsenwol, O.; Talmor, D. (2012). "Tainted Love: exploring relationship-centered obsessive compulsive symptoms in two non-clinical cohorts". Journal of Obsessive-Compulsive and Related Disorders. 1 (1): 16–24. doi:10.1016/j.jocrd.2011.11.002.
  17. ↑ How Relationship Substantiation can Jeopardize your Romantic Life http://www.obsessivecompulsions.com/rocd
  18. 1 2 The Treatment of Obsessions by Stanley Rachman. Oxford University Press, New York, N.Y., 2003 Reviewed by Dean McKay, Ph.D., A.B.P.P. Fordham University, Bronx, New York
  19. 1 2 Concepts and Controversies in Obsessive-Compulsive Disorder Source: Springer Science, Business Media Author(s): Abramowitz, Jonathan S.; Houts, Arthur C.
  20. ↑ G.S. Steketee, R.O. Frost, J. Rhéaume and S. Wilhelm, Cognitive theory and treatment of obsessive-compulsive disorder. In: MA Jenike, L Baer and WE Minichiello (Eds.), Obsessive-Compulsive Disorder: Theory and Management. (3rd ed., pp 368-399) Chicago: Mosby.
  21. ↑ http://www.ocdonline.com/definecbt.php
  22. ↑ Understanding and Treating Obsessive-Compulsive Disorder: A Cognitive Behavioral Approach, Lawrence Erlbaum Associates, Inc.; 1 edition (September 2, 2005)
  23. 1 2 Purdon, C.A. & Clark, D.A. (2005). Overcoming Obsessive Thoughts: How to gain control of your OCD. Oakland, CA: New Harbinger.
  24. 1 2 Obsessive Compulsive Disorder Research, By B. E. Ling, 2005. Nova Science Pub Inc. Page 128
  25. ↑ http://www.ocdonline.com/articlephillipson1.php/

Bibliography

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