Obsessive-Compulsive Disorder

Compare and Contrast a Psychodynamic/Psychoanalytic and a Cognitive-Behavioural Approach to the Understanding and Treatment of Obsessive-Compulsive Disorder. Which approach do you prefer and why? Obsessive-Compulsive disorder is not yet fully understood, and thus is presently the subject of a number of possible theories regarding its origin and treatment. Despite this controversy however, a number of basic facts regarding the symptoms and diagnosis of the disorder remain consistent among all these approaches (it is the cause and treatment that is under question, not the form the disorder itself takes).

The basic symptoms of Obsessive-Compulsive disorder centre on the afflicted individual suffering from constant obsessive thoughts of an unpleasant and unrealistically excessive nature (such as that of being contaminated by germs, or wanting to do harm to a family member). This obsession is seen to cause great anxiety in the sufferer, which is temporarily alleviated through the compulsive repetition of a ritualistic act or thought (excessive washing, repeating a particular line over and over etc).

What originally causes these obsessions to occur, what form they take, and how they can be dealt with is not nearly so straightforward. It is these questions that have led to the development of a number of competing views. The Psychodynamic/Psychoanalytic (in this circumstance these terms prove to be interchangeable) view focuses on internal, unconscious conflicts their and displacement. The Cognitive-Behavioural viewpoint bases itself on a lowering of defence mechanisms that allows anxiety to develop to the extent that self-perpetuating obsessive-compulsive cycles are formed.

Although these two viewpoints are seen by the psychological community as opposed, the lack of empirical evidence means that neither can be said to be totally correct, and thus it is not impossible that the two may be reconciled to some extent. When discussing the understanding of Obsessive-Compulsive disorder from the two aforementioned viewpoints, it is useful to note that they both have strengths and weaknesses, and these do not appear to overlap.

Namely, the Psychodynamic viewpoint is particularly strong in its description of how and why the obsessions originate as well as explaining the form the obsessions and the compulsions take, but is rather week on the persistence of the disorder. The Cognitive behavioural viewpoint on the other hand is not as strong on the origins of the problems, but focuses on the behaviour involved and so on the persistence of the illness.

The Psychoanalytic account finds its roots in Freudian theory. He claimed that it represented a failure to resolve the anal psychosexual stage, and the result was personal failures, conflicts or problems being forced into the unconscious as the superego could not reconcile itself with such problems. This ‘bottling up’ caused severe mental problems and as such the angst was displaced onto a less unacceptable alternative (the obsession) to stop the ego defences from becoming overwhelmed. In the same vein, the compulsions represented reaction formations to the negative thoughts or impulses through symbolic, diametrically opposed behaviours. A compulsion for cleaning or washing represented the cleansing of the unconscious wishes, undoing something is cancelling these wishes, and laborious or personally harmful tasks represented atonement, etc (Freud, 1976)

While much of Freudian theory has been extensively revised, the core components often remain, and that is true in the case of the psychodynamic approach to Obsessive-Compulsive disorder. The current Psychodynamic stance is very similar, but does not focus on the ‘psychosexual stages’ or the concepts of the id, ego and superego. Instead it suggests that the obsession can spring from the displacement and substitution of any repressed issue that causes great anxiety and threatens to invade conscious thoughts.

This displacement will not be arbitrary, but rather will have some basic link to the original repressed thought or action. A popular example is that of a woman who suffered great anxiety and ‘burning sensations’ when confronted with what she considered ‘hot colours’ (such as red and orange). The anxiety and suffering would become debilitating unless she could look at a ‘neutral colour’ such as blue, green or white (Rachman and Hodgeson, 1980).

When her case history was traced back, the Obsessive-Compulsive disorder was seen to develop at a time when the woman feared greatly for the health of her ailing mother, with her thoughts focussing on the fact that if her mother suffered a fever she could die. The Psychodynamic explanation suggests that it was this fear over her mothers health that was repressed, and transferred to a more suitable substitute (in this case her own health). In this case the obsession over hot colours was directly linked to fear of her mother getting the potentially fatal fever.

The Cognitive-Behavioural approach is significantly different to this, suggesting that the development of Obsessive-Compulsive disorder is an extreme reaction to the obsessive thoughts that all people suffer from time to time. It is said that any thought or action that produces anxiety leads to focussing or obsessing on the issue for a short period, but ‘normal’ people can usually dismiss this fairly quickly. The more upset an individual is made by an anxiety producing stimuli, the longer these intrusive and repetitive thoughts last (Horowitz, 1975).

Moreover, the more depressed or stressed an individual is, the more susceptible they are to these obsessive thoughts (Seligman, 1975). The act of distraction or dismissal from such thoughts is both conscious and voluntary, and in extreme cases an individual can find themselves so anxious and depressed that they are unable to help themselves in this way. This inability to react in turn leads to greater levels of anxiety and depression, which results in the obsessive thought becoming entrenched. The compulsions seen are a way to temporarily alleviate these anxieties through the ritualistic execution of some superficial neutralisation.

The anxiety relief that they cause only temporarily reduces the symptoms, however, and do not effect the cause, which means that not only is the disorder not cured, but moreover it becomes worse as the temporary relief of the compulsions is taken up more regularly. It can even be argued that the anxiety can be further accentuated by the fact that the relief is only temporary, yet the obsessions remain.

This approach is often applicable to Obsessive-Compulsive disorder cases, such as one which involved a 38 year old mother who became obsessed with contamination by germs and led her to extensive cleaning rituals including confining her child to only one room of the house, which she scrubbed a number of times a day. In this case it could be said that the anxiety over the germs came at a time when she was particularly emotionally vulnerable (after the birth of her child) and the rituals were a natural response to the obsession. Moreover, the statistics that within Obsessive-Compulsive disorder sufferers, obsessive incidents triple at times of depression (Videbech, 1975). This approach, with its focus on the effects of anxiety, also puts a strong case forward for the perpetuation of the disorder, which the Psychodynamic approach fails to deal with.

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