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Treating OCD: Harnessing Fear to Catalyze our Growth

Will Atkinson | January 23rd, 2024

How often have you heard someone describe themselves as “so OCD” because they like to keep a neat room? Or because they maintain an organized calendar? Being perhaps the most trivialized mental disorder, Obsessive Compulsive Disorder (OCD), despite its prevalence in American vernacular, is one of the least widely understood mental disorders. Having recently been removed from the anxiety disorder classification and been recognized as its own monolithic disorder in the Diagnostic and Statistical Manual of Mental Disorders, Steven Zauderer from Cross River Therapy states that OCD affects roughly 2.5 million adults in the US alone, or about 1.2% of American adults. 

By what, exactly, is OCD defined? OCD can be conceptualized as a pattern of distorted thinking: a series of intrusive thoughts circulating a specific topic that the patient attempts to alleviate by performing specific compulsions. Trying to comprehend the first component of this disorder – the intrusive thoughts – represents the most substantial barrier to understanding this disorder. Everyone, both those with and without OCD, have intrusive, disturbing thoughts. The distinguishing element of OCD-intrusive thoughts is their magnitude of evoked perturbation and their persistence. For example, one of the classic examples of OCD is a fear surrounding bacterial hygiene. A possible manifestation of this fear is, following contact, or perhaps just potential contact, with a public surface like a table in a dining hall, the patient, as a consequence of some thought that diagnoses the contact with the service as unequivocally bad and dangerous, will experience both a general anxiety spike along with psychosomatic symptoms of illness such as a headache, dizziness, and feelings of a fever, possibly for several days.

The second component of OCD is the engagement of compulsions, whether mental or behavioral, in order to mitigate any negative affect elicited by the intrusive thought. In the example of a germaphobia-related manifestation of OCD, a common compulsion could be what is generally considered to be “excessive” hand washing. Additionally, the patient would likely fall victim to trying to rationalize and convince themself that, contrary to their fear, they are wholly unharmed by the exposure. While rationalizing may initially seem the natural and appropriate response to the rush of fear, the attempt to answer the question that OCD asks the patient further entrenches them in the OCD, as the question can never be definitively answered.

I find it important to note that I chose to use the example of hygiene due to its leading to a more visible compulsion, but it is certainly far from the only type of OCD that can be experienced. One of the challenges with OCD and its treatment is that it can latch onto wide-ranging and seemingly innocuous ideas – such as a fear of misspeaking in a classroom, or an unknowing of the existence of the divine, or even a fear of brain injury – and completely subvert the life of its host.

The phenomenon of OCD can be further understood by dissecting its preeminent treatment – Exposure and Response Prevention (ERP). Dianne Hezel and Helen Simpson assert that while “people with [OCD] did not respond that well to traditional psychodynamic psychotherapy, medication, or available behavioral interventions,” the 1960s clinical application of ERP represented the “The first significant non pharmacological advance in treatment”. According to Hezel and Simpson, ERP follows a model of habituation: patients are “exposed to feared stimuli while [being asked to refrain] from performing compulsions.” The idea is that by exposing themself to the stimulus, the patient will experience a spike in anxiety, but, as a consequence of not engaging in the compulsive and relieving behavior, their fear response will be slowly degraded. Following the example of a patient with a hygienic-based fear with hand-washing compulsions, a potential exposure could be the touching a railing that parallels a flight of stairs and refraining from washing their hands for an hour. The next time, the patient may be asked to wait an extended length of time before washing their hands, or instead may be asked to eat (or whatever else will induce additional fear) before washing their hands. Through frequent and increasingly intense exposures, the patient should hope to see a decrease in their aversion to activities that their fear had previously influenced as well as a decreased fear response in the event of those fearful activities.

In order to learn more about the contemporary research into this psychiatric disease and its treatment, I had the pleasure of sitting down with one of, if not the most, accomplished Vanderbilt professors, Dr. Bunmi Olatunji of the Vanderbilt University Psychology department. Beginning in graduate school at the University of Arkansas, Olatunji took a fascination in the study of OCD. For him, it was specifically “the heterogeneity of symptoms that [are] seen,” and that his patient “on Tuesday could look nothing like [his] patient on Thursday.” 

Olatunji operates at the intersection of many components of the OCD field, operating as a clinician, a researcher, as well as a professor, all of which responsibilities he finds to “synergistically” inform each other. For example, his large research portfolio has allowed him to identify a variant of OCD that strays from the traditional fear-driven and instead is disgust-driven – which has been more resistant to ERP intervention. This discovery has led him and his team to theorize that “rather than leaning on habituation as a mechanism for ERP, [they may] have to [adjust their approach] for disgust” to instead focus on effort on increasing “distress tolerance.” He then applies this modified goal to concoct a plan to treat a patient who experiences a disgust-based OCD. Finally, he teaches his undergraduate and graduate students the research and clinical practice techniques that contributed to the patient’s eventual Exposure and Response Prevention treatment.

While ERP is thought to be the “gold standard for OCD treatment,” it does not come without its challenges, as “about 50% of patients [either] don’t benefit or relapse.” One of the obstacles involved is that ERP essentially asks the patient to identify what behavior would evoke substantial fear, engage in that behavior, and then refrain from engaging in whatever behavior would grant them reprieve. And to a patient with an irrationally high fear response to specific behaviors, the commitment to this style of treatment can be onerous. Beyond the patient’s aversion to committing to ERP treatment, depending on the type of OCD and the nature of the intrusive thoughts, exposures can be difficult to create and compulsions can be elusive and nearly inseparable from the patient’s personality – how does a high achieving perfectionist who compulses by testing themself minimize their cognitive testing whilst maintaining both their personality and performance? “Within the next five to ten years,” Olatunji outlines, “it’s really going to be how do we maximize the benefit of ERP.” 

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