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 consultation with symptoms solely based on obsessions..

This is what is known as pure OCD or pure obsessions. Obsessions can be defined as recurrent 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 anxiety or significant discomfort.

Compulsions usually cause very short-term relief. The anxiety or tension felt due to obsessions is negatively reinforced by the compulsive behavior.

This compulsion causes the problem to persist and become chronic. because the patient learns that it is the only means available to get rid of anxiety and the unpleasant thoughts that inhabit his mind.

Compulsions are generally not realistically connected to the event. that what is feared will not happen or are clearly excessive. For example, a patient may believe that if she claps three times as she leaves and enters the door of her house, then her husband will not be in a car accident on the way to work.

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

The key is habituation

The fact that obsessions are negatively reinforced by practicing the compulsion leads to non-habituation to the anxiety or fear that they generate.

Therefore, obsessions are fed; and by feeding them progressively, they gain weight. Likewise, in pure obsessive disorders, treatment is based on habituation and for this to occur it is essential to be exposed to one’s own obsessions.

Many times the exposure is aversive for patients. Exposure with response prevention can lead to significant rejection and even treatment abandonment. This is one of its disadvantages; However, to date, 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 goal, finally, is for the person to expose themselves to their thoughts or images so, voluntarily, you must take them outside and “look into their eyes.” Habituation training arises from the research of Salkowskis and Westbrock.

It is usually carried out on an audio tape in which the patient records his pure obsessions and listens to them repeatedly until he gets used to it. to them. The predictability of the stimuli to which the subject is exposed is the key factor in the treatment. Through 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 audio recording, you can use Other strategies to present thoughts in predictable ways: deliberate evocation of them by narrating them in session or putting them in writing and rereading them until the anxiety decreases.

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 certain 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 pointed out, when a person is exposed to the fears of it (whether through images, live or in the case of pure OCD by recording or in writing) experience a substantial increase in anxiety.

This moment is key because the patient thinks that It’s worst And you’re right, you feel much more anxious. But that unpleasant rise is finite. Physiologically and inevitably, the rise in anxiety has a limit.

When this discomfort reaches its maximum point and if the patient does not perform any rituals, safety behaviors or any other avoidance, anxiety will begin to decrease progressively. Why is this happening? First of all, on an emotional level, anxiety, nor any other emotion, increases linearly. It is not the characteristic pattern. There has not been any case in which the emotion rises and rises until it kills anyone. Not at all.

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

In short, the fundamental thing is to prevent the patient who is going to be exposed to his obsessions or any other stimulus that causes anxiety from knowing that maintaining 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 rather increases it.

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