Obsessions are elements of thought (images, memories, words, etc.) that torment a person and push them to produce a response that “switches them off,” at least temporarily. Regardless of their content, the person recognizes them as thoughts generated by their own brain because they occur without any possibility of choosing whether or not to let them in. There is no “incoming” control on the part of the person, who experiences them passively and cannot continue thinking or acting until they have first attenuated them. Technically, they are said to be “ego-dystonic,” meaning, in simple terms, that they interfere with the activities the person wants to carry out by “pulling” their attention and concern toward other mental directions. To keep obsessions under control, people develop rituals, that is, behaviors that can be repeated 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, like an instinctive reaction, they are called “compulsions.”
Some obsessions are immediately paired with compulsions through a rapid and instinctive mechanism (for example: thought of dirt → compulsion to wash oneself). In other cases, the person develops rituals to drive away obsessions according to a logic based on their content (e.g., a thought about committing obscene acts is driven away by making the sign of the cross), while in other cases the ritual is simply something “invented” by the person (e.g., counting to three to drive away the obsession, or making a facial grimace).
Are compulsions therefore rapid and simplified rituals for keeping obsessions under control? The answer is simply no. The obsession-compulsion pair is not a balanced pair; rather, it is the source of a disorder that progressively worsens.
Over time, the rituals that have been developed tend to evolve unfavorably: either they become more complicated, perhaps needing to be repeated several times, with 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. If, at first, a person thinking about unpleasant images would spit on the ground to drive away the obsessions, later they may simply spit without even 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 compulsion may come first and then, through a kind of “reverse” mechanism, the obsession itself may emerge clearly afterward, even though it was initially implicit.
Rituals worsen obsessions. During rituals, the person’s thoughts remain fixed on the obsessions, and therefore it is common that precisely when the ritual gesture or behavior is completed in an attempt to “close” the obsession, the obsession resurfaces even more intensely than before, forcing the person to immediately repeat the ritual that has just been completed. The ritual (or compulsion, as it may be called) is the fuel of obsessive-compulsive disorder: it feeds itself and, at the same time, feeds the obsessions.
Some rituals are communicative because they concern obsessions to which the person seeks answers. In these cases, the rituals take the form of questions that are repeated periodically, often exasperating the person who has to answer them. Moreover, they are typically requests for reassurance, and therefore their content is often so generic and undefined that they cannot be easily answered. The obsessive person will insist on the precision of the answer they need, introduce new details, feel that they have not explained themselves properly or that they 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, fears of having illnesses), in which the person turns to a doctor for reassurance, but by describing the problem actually increases the obsession; and as soon as they receive the answer (negative), they are once again overwhelmed by the obsession that they may have the illness.
In these cases, the compulsion consists of reasoning through the doubt about having an illness in order to cancel it out with a convincing answer. Over time, the compulsion to reason becomes an autonomous focus of its own, which reactivates the obsession itself and carries it along with it.
Obsession pushes people to go off course very quickly, that is, to believe that the answer to the obsession and the other rituals constitute a way out. This soon creates a conflict with the person trying to respond, 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 any answer to the obsessive question. In the case of a hypochondriacal obsession, for example, the person will tend to believe 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 on interrupting, through different techniques, the obsession-compulsion-obsession cycle. The inability to perform the rituals, although initially accompanied by intense anxiety, eventually produces a reduction in both compulsions and obsessions.
In summary, the course of obsessive-compulsive disorder becomes unfavorable when:
the person reacts to explanations by believing that they have not been understood, that they have not explained themselves properly, or becomes irritated because they have not received a convincing answer and believes that obtaining such an answer was the purpose of the consultation;
the person seeks, perhaps by repeatedly consulting different doctors, a doctor who will provide reassuring answers. If the doctor limits themselves, as they should, to treating the obsessive-compulsive disorder, the patient may instead try to push the doctor to focus on the obsessions and provide an answer to them, emphasizing the symptoms in an attempt to obtain reassurance and avoid being “dismissed”;
the person is unable to refrain from repeating the same questions at the end of the discussion and cannot accept that the doctor deliberately does not provide an answer, as though the doctor were refusing out of spite or because of an aloof attitude.
Hypochondriacal obsessions are particularly difficult to manage because the doctor is also the person who is expected to manage the 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 to accept this approach, but otherwise it is almost certain that the obsessions will worsen and that the relationship with the doctor will eventually become impossible anyway.
Anti-obsessional pharmacotherapy and cognitive-behavioral psychotherapy are first-line tools for controlling obsessive-compulsive disorder. Since this is a disorder that is associated in some cases with bipolar mood disorders, psychotherapy may sometimes be useful in carrying out anti-obsessional work while minimizing the use of antidepressants, which could destabilize mood, impulsivity, and aggression.