Obsessions are elements of thought—images, memories, words, and so on—that torment a person and drive them to produce a response that “switches them off,” at least temporarily.
Regardless of their content, a person recognizes them as originating in their own mind because they occur without the possibility of choosing whether or not to let them in. There is no “input control” on the person’s part: they experience the thoughts involuntarily and cannot continue thinking or acting until they have somehow reduced their intensity.
Technically, they are described as “ego-dystonic,” which, in simple terms, means that they interfere with the activities the person actually wants to engage in by “pulling” their attention and concern toward other mental directions.
To keep obsessions under control, people develop rituals, meaning behaviors that they can repeat whenever an obsession occurs and that temporarily allow them to overcome the obstacle created by the obsession.
When these behaviors are irresistible and occur immediately, almost like an instinctive reaction, they are called “compulsions.”
Some obsessions become immediately paired with compulsions through a rapid and instinctive mechanism—for example, a thought about dirt or contamination followed by a compulsion to wash.
In other cases, the person develops rituals to drive away the obsessions according to a logic based on their content—for example, a thought about committing obscene acts is driven away by making the sign of the cross.
In other cases, the ritual is simply something the person has “invented” themselves—for example, counting to three to drive away the obsession, or making a particular facial grimace.
Are compulsions simply quick and simplified rituals for keeping obsessions under control?
The answer is simply no.
The obsession-compulsion pair is not a balanced system; rather, it is the source of a disorder that progressively worsens.
Over time, elaborate rituals tend to evolve in an unfavorable direction: either they become more complicated, perhaps having to be repeated several times or involving increasingly long and precise sequences of actions, or they become automatic.
In some cases, what remains of the obsession-compulsion pairing is precisely the compulsion, while the obsession does not even have time to fully emerge.
For example, if at first a person, when thinking about unpleasant images, would spit on the ground in order to drive away the obsessions, later they may simply spit without even consciously focusing on the thoughts.
Rituals can therefore become a problem in their own right, attaching themselves to the obsessions and making the disorder more complicated.
In fact, the process can sometimes work in the opposite direction: the compulsion occurs first and is then followed by the clear emergence of the obsession, which appears afterward and generally remains implicit.
Rituals make obsessions worse.
During rituals, the person’s attention remains fixed on the obsessions. Consequently, it is common for the obsession to return even more intensely precisely when the person completes the ritual act or behavior intended to “close” the obsession, forcing them to immediately repeat the ritual they have just completed.
The ritual—or compulsion, if you prefer—is the fuel that sustains Obsessive-Compulsive Disorder (OCD): it feeds itself and, in turn, feeds the obsessions.
Communicative Rituals and Reassurance-Seeking
Some rituals are communicative, because they concern obsessions for which the person seeks answers. In this case, they take the form of questions that are repeated periodically, often exasperating the person who has to answer them.
Moreover, these are typically reassurance-seeking questions, and their content is therefore often so general and undefined that they do not have an easy answer.
The obsessive person will insist on obtaining a precise answer, introduce new details, feel that they have not explained themselves properly or have not been listened to carefully enough, or believe that their problem has been underestimated.
This type of situation is typical of hypochondriacal obsessions—that is, obsessions about having illnesses—in which the person turns to a doctor for reassurance. However, explaining the problem actually intensifies the obsession, and immediately after receiving a negative answer, the person is once again overwhelmed by the obsession that they may have the illness.
In these cases, the compulsion consists of reasoning through the possibility of illness in an attempt to cancel the doubt with a convincing answer.
Over time, the compulsion to reason becomes an autonomous source of obsessive thinking, which reactivates the obsession itself and carries it along with it.
The Obsessive Cycle
An obsession quickly pushes people “off track,” leading them to believe that answers to the obsessions and other rituals are a way out.
This soon creates a conflict with anyone who tries to provide an answer, because the answers will never be satisfactory, or will not remain satisfactory for long.
The therapist will try to explain the obsessive mechanism to the person without, however, providing an answer to the obsessive question itself.
In the case of a hypochondriacal obsession, for example, the person will tend to think that what is needed is a simple and exhaustive answer, almost like a kind of “magic touch” that will switch off the obsession once and for all.
They will be reluctant to accept that the solution to the question is instead the extinction of the question itself, with no further answers.
This may not provide immediate relief, but over time it prevents the obsession from being reinforced.
Some psychotherapies for obsessive-compulsive disorder are based precisely, using different techniques, on interrupting the obsession-compulsion-obsession cycle.
The inability to perform the rituals, although initially accompanied by intense anxiety, eventually leads to a reduction in both compulsions and obsessions.
When Does Obsessive-Compulsive Disorder Worsen?
In simplified terms, the course of obsessive-compulsive disorder tends to worsen when:
- One reacts to explanations by believing that one has not been understood, that one has not explained oneself properly, or becomes irritated because one has not received a convincing answer and believes that obtaining that convincing answer was the purpose of the consultation.
- One searches for a doctor who will provide reassuring answers, perhaps by repeatedly changing doctors. If the doctor appropriately limits themselves to treating the obsessive-compulsive disorder, the patient may instead try to push the doctor into focusing on the obsessions and providing an answer to them, emphasizing the symptoms in an attempt to obtain reassurance and avoid being “dismissed.”
- One is unable to stop repeating the same questions at the end of the discussion and cannot accept that the doctor may deliberately refrain from answering, as though the doctor were doing so out of spite or because of an unfriendly or dismissive attitude.
Hypochondriacal obsessions are particularly difficult to manage because the doctor is also the person who would normally be responsible for arranging investigations for the illnesses the patient fears.
The good doctor, however, is the one who treats the obsessive disorder as such and does not use the patient’s fears as a guide for ordering tests, discussing symptoms, and so on.
Unfortunately, patients may initially refuse or resist this approach. If they do not accept it, however, the obsessions will almost certainly worsen, and the relationship with the doctor will ultimately become impossible anyway.
Treatment
Anti-obsessional pharmacotherapy and cognitive-behavioral psychotherapy are first-line tools for managing obsessive-compulsive disorder.
Because obsessive-compulsive disorder is associated in some cases with bipolar mood disorders, psychotherapy can sometimes be useful for carrying out anti-obsessional work while minimizing the use of antidepressants, which could potentially destabilize mood, impulsivity, and aggression.