Here we go round again

“And now we’re back where we started

Here we go round again

Day after day I get up and I say

I better do it again” 

            Ray Davies/The Kinks

 Compulsions refer to a set of behaviors, within the context of obsessive-compulsive disorder. So, this means I am leaving out a lot of other behaviors that some people call compulsive, involving substance use, shopping, or pornography. I am leaving this out so we can get some clarity and specificity about to talk about. 

 According to the diagnostic manual, the DSM-5, compulsions are: 

Repetitive behaviors that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. The behaviors are aimed at preventing or reducing emotional distress, or preventing some dreaded situation. The behaviors are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. Whoa, that is a lot of dense content crammed into two sentences. Let’s unpack it all piece by piece. 

 The definition starts with Repetitive behaviors… what exactly does this mean though? I like applying Low’s definition of stereotypy to flesh out what we mean by repetitive behaviors: “a behavior or sequence of behaviors being repeated in excess of their normal functional requirements.”

 Ok, now that we have a grip on repetition, this comes next - that the individual feels driven to perform…so this part is not about the behavior itself, but describes an unpleasant feeling state that precedes the behavior. We can call this an urge that feels like being pulled to action. This urge can be strong, sometimes incredibly strong and difficult to resist. 

 in response to an obsession or according to rules that must be applied rigidly. so this places the behavior in the context what we can call the “OCD cycle” (more on this later). The compulsive act comes after an obsession thought. Thus obsession and compulsion are joined together. But the definition adds an additional phrase reminding us that alternatively a compulsion can occur when I rigidly apply a rule or a set of rules regardless of context. (“all doorknobs are dirty”). 

 Quick recap. Compulsions are repetitive behaviors that go above and beyond what the situation requires. Before the compulsions there is an urge to do the compulsion, and before the urge,there is an obsession. Thus obsession, urge and compulsion form a cycle. Now onto the next part of the definition. The behaviors are aimed at preventing or reducing emotional distress,…now we get to the purposes of the behavior. This first one is emotion focused. The behaviors are aimed at reducing anxiety, disgust, shame, horror when we are triggered. But in addition, I might also start behaving compulsively to prevent even getting triggered. 

 Besides preventing or reducing emotional distress, compulsions are also aimed at “…preventing some dreaded situation.” There are an infinite variety of dreaded situations including death, illness, burglaries, fires, theft, injury, becoming homeless, getting arrested, or even offending someone. Do I need to go on? You get the idea. Let’s add one more type of dreaded situation: the possibility of being a deviant, pariah, morally corrupted or sick person. 

 I wish the DSM-5 had added a little piece saying “compulsive behaviors can also be aimed at preventing or getting rid of the obsession thought”. Think of your mind as the space where your self or your consciousness lives. We don’t want obsessions that are gross, sick, perverse, scary, or just plain awful to invade and then become “squatters” in our mind space.  So we employ actions to try and get I’d of these thoughts. Thought replacement, praying, chanting can become compulsive strategies to try to remove obsessions from our mind. 

 The compulsive checklist

 Here then is our checklist to see if a behavior is compulsive:

●      Is it very repetitive? 

●      Does the person feel really driven to perform it?

●      Is the behavior part of the OCD cycle, in which it is in response to an obsession? Or part of a set of rules that must be followed rigidly?

●      Is it aimed at reducing distress, a dreaded outcome or removing a bad thought from my mind?

The Compulsive Big Six

 The central aim of a compulsion is to do one or more of the following: 1) reduce feeling bad, 2) make a dreaded outcome less likely; 3) remove a bad thought from my mind. OCD specialists have described compulsions in many different ways and broken them down into many different categories. Here’s my stab at it. 

 Rituals

Cleaning

Checking

Reassurance providing

Mental neutralizing

Avoiding

 Rituals are formula-ized actions. Do the action in the same way each time. They are done in a standardized manner, with a set order, with  fixed repetitions and mannerisms. Deviations are not allowed and the whole thing has to be repeated if even small alterations are made. Praying, chanting, lifting weights, maybe even baking can be ritualized but NOT compulsive. What makes a ritualized behavior compulsive? Well, let’s go back to the compulsive checklist above. And just a final note, I can be repetitive but not ritualized. I can do something over and over, like something observable like washing, or something more internal, like worrying. However, it may or may not be done in a ritualized manner with a fixed order, number of repeats, a fixed number of things that I think about, a fixed way I think about it etc. So being ritualized is different from being repetitive.

Cleaning compulsions range from showering, hand washing, tooth brushing, using sanitizer to doing laundry. Cleaning compulsions can also involve excessive cleaning of rooms or items around the house (or getting someone else to clean around the house). They are very often ritualized, but not always. Even if the cleaning is not ritualized, there’s not a lot of flexibility and it’s almost always rigid. 

 Checking How do I know that I know something? Knowing is a sense. 2 + 2? I know the answer and I know that I know the answer. 47231 + 3428 = ? I don’t know the answer but I know that can know it (by doing the math) fairly easily. Imagine the opposite. I recognize someone; I know that I know them but I just can’t place them. I don’t know their name or who they are. Then maybe in a few minutes it will come to me. That’s Bob from my old macrame class. What if this sense of knowing was malfunctioning in a few specific areas? Is the door locked? Did I do something wrong a while ago and I can’t remember for sure? Checking (really rechecking and rechecking) can take shape is such a variety of ways - staring, retracing my steps, checking the house alarm, checking the faucets.

 Reassurance is a checking-adjacent behavior. Like checking, reassurance seeking is a confirmation seeking action, but it has a social piece to it, in that it involves lots of repetitive asking (“Did I wash my hands properly?”, “Did I just run someone over? Did I just say something offensive to someone?” Sometimes an answer from another person isn’t even needed, just the action of asking for reassurance fulfills the requirements of the compulsive urge. In contrast to reassurance questions, reassurance can also be an answer I repetitively tell myself basically saying “I’m ok, it’s ok, everything is going to be ok” “I didn’t do that bad thing”, “I’m not a bad person”. 

 Mental Neutralizing is aimed at mental “undoing”.  Freeston and Ladouceur (1997)  describe a neutralizer as an act aimed at removing, preventing or weakening the obsession or the anxiety or distress that accompany it. As an example, I can imagine a good thought after having a bad one, the idea is to undo the bad thought. Chanting, praying, repeating a particular phrase, taking an  obsession word and repurposing it somehow can be a neutralizer as well. 

 Avoidance. The lure of avoiding triggering situations, people, images, and thoughts can be extremely strong. And avoiding is not necessarily bad. In fact it can be very helpful. But when avoiding causes a progressive narrowing or constricting of my life experiences, when I repeatedly turn away from my triggers, it can make me even more sensitive to anxiety. So in fact in my attempt to get away from anxiety, I become more anxiety sensitive. This means I feel it more intensely and in response to an ever expanding list of triggers. 

 Perhaps all of these actions I’ve discussed can be called “actions to escape from feeling bad”. The frequent use of these avoidant strategies produces more and more anxiety. Why would we do something that causes the thing we are trying to get away from? The answer is not so easy, but in OCD, the answer lies at least partially in an understanding of habitual behaviors. 

 Our minds are built to automate. It is a deep, deep aspect of how our minds handle engaging with the world.

 Think about driving. Think about a golf swing, or a tennis serve, or even beating an egg. Think about the 15-20 times you did those things. Remember how awkward and unnatural they were? 

 Think about how you drive now (if you do). You know how to turn the wheel to turn the car, how much pressure your foot needs to slow the car down. All so routine and natural now. I bet you can parallel park like a boss now. But not at first right? So driving has become habitualized. What does that mean? It means that you have integrated a complex chain of fine and gross motor movements, blended seamlessly with “hand-eye” coordination. If you play a lot of golf, even if you don’t like your golf swing right now, compare it to someone just starting out. For better or worse, their swing is not habitualized yet. 

 A complex chain of behaviors that are habitualized are semi-automated. This means that I don’t have to devote much thought to them. Sometimes your coach or piano teacher might even encourage you to “not think so much” because it might be getting in the way.

 Sometimes when you do these habitualized behaviors you might get a little “ah” feeling - like when your forehand in tennis hits the ball right in your racket’s sweet spot; or when you hit a smooth consistent stride while running. It feels right - and the reward is a feeling that it feels right. We don’t get that feeling all the time, but we know it and remember it and hope for it. 

 So far so good. This is the sunny side of the story. But, as you know there are problematic habits. My old guitar teachers used to tell me variations of  “practicing bad form teaches bad form” and “slow down! Playing fast and making mistakes  teaches your fingers to keep making those mistakes.”

 An interesting thing about habits is that they seem to be independent of distant, “objective” rewards and punishments. I fall victim to doing the habit despite my knowing it isn’t “good for me”. Learning theorists speculate this is because habit behaviors are not tightly tied to our sense of goal driven action, but are more stimuli triggered.  

 So, I hope this overview gives you a sense of how complicated and difficult it is to have OCD or chronic anxiety. I hope this write up conveys how hard it is to work on getting better. It’s not easy, but it can be done, step by step.