Obsessive-Compulsive Disorder as a Pathology of Stopping, Rather than Starting

[Daniel E.]

When Too Much Is Not Enough: Obsessive-Compulsive Disorder as a Pathology of Stopping, Rather than Starting

In obsessive-compulsive disorder (OCD), individuals feel compelled to repeatedly perform security-related behaviors, even though these behaviours seem excessive and unwarranted to them. The present research investigated two alternative ways of explaining ...

www.ncbi.nlm.nih.gov

(2012)

Abstract​

Background​

In obsessive-compulsive disorder (OCD), individuals feel compelled to repeatedly perform security-related behaviors, even though these behaviours seem excessive and unwarranted to them. The present research investigated two alternative ways of explaining such behavior: (1) a dysfunction of activation—a starting problem—in which the level of excitation in response to stimuli suggesting potential danger is abnormally strong; versus (2) a dysfunction of termination—a stopping problem—in which the satiety-like process for shutting down security-related thoughts and actions is abnormally weak.

Method​

In two experiments, 70 patients with OCD (57 with washing compulsions, 13 with checking compulsions) and 72 controls were exposed to contamination cues—immersing a hand in wet diapers —and later allowed to wash their hands, first limited to 30 s and then for as long as desired. The intensity of activation of security motivation was measured objectively by change in respiratory sinus arrythmia. Subjective ratings (e.g., contamination) and behavioral measures (e.g., duration of hand washing) were also collected.

Results​

Compared to controls, OCD patients with washing compulsions did not differ significantly in their levels of initial activation to the threat of contamination; however, they were significantly less able to reduce this activation by engaging in the corrective behavior of hand-washing. Further, the deactivating effect of hand-washing in OCD patients with checking compulsions was similar to that for controls, indicating that the dysfunction of termination in OCD is specific to the patient's symptom profile.

Conclusions​

These results are the first to show that OCD is characterized by a reduced ability of security-related behavior to terminate motivation evoked by potential danger, rather than a heightened initial sensitivity to potential threat. They lend support to the security-motivation theory of OCD (Szechtman & Woody, 2004) and have important implications both for research into the biological mechanisms underlying OCD and for the development of new treatment approaches.

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[Daniel E.]

From the end of the article:

Possible Therapeutic Implications

The present results also have important therapeutic implications. First, although exposure with response prevention (ERP), the prevailing psychotherapeutic treatment for OCD, is quite effective, a sizeable proportion of patients do not comply with or find they cannot tolerate ERP. The perspective advanced here provides a different way of explaining to patients the underlying nature of their difficulties, which, by linking OCD to normal psychology, may connect better with their experiences, thus providing a more acceptable rationale for treatment and enhancing persistence with its difficult challenges. In particular, it may be explained to patients that OCD symptoms occur in response to cues that activate a normal, biologically primal motivational system that protects people from potential danger.

However, security-related behaviors that for most people would readily shut down these primal concerns do not work well in people with OCD. Thus, OCD patients repeat these behaviors in an attempt to overcome their weak internal stop signal, which explains why ‘‘too much is not enough.’’ Leahy [71] has integrated this kind of explanation successfully into a CBT-based treatment protocol.

Second, complementing the emphasis in CBT on obsessive thoughts in OCD, the perspective advanced here highlights the role of compulsive behavior. Although compulsive responses are blocked in ERP treatment, recent research indicates that this is not necessary for treatment success; indeed, the opposite possibility, response intensification, may be as effective [72]. Thus, manipulation of compulsive behavior patterns and their negative-feedback function may offer new avenues for treatment.

The basic idea would be to develop techniques to teach, or compensate for the weakness of, the security-satiety or stop signal. For example, some work suggests that hypnotic suggestions [73] and biofeedback [42,43] can either block or attenuate confidence in internal signals. Hence, it is possible that such techniques can also be used to intensify or enhance the internal stop signal. Pharmacological interventions might also be developed for such enhancement.