As discussed in A Simple Explanation of OCD, OCD always centers on a fear of making an irreversible mistake that leads to experiencing a certain form of emotional distress forever; this is the Core Fear.
But sometimes a person with OCD will say that they aren’t afraid anything bad will happen if they don’t do their compulsions. They’re often at a complete loss to explain why they’re doing what they’re doing.
These individuals often present with:
- A need to get something ‘just right’
- A need to do a ritual that isn’t connected, even magically, to preventing something bad from happening
- A need to do a certain behavior simply because the idea comes to mind (e.g., watching pornography)
In these cases, the urge itself is experienced as distressing, and the person is afraid that the distressing urge will persist until they do the compulsion (and in some cases, that it could become permanent if they don’t do the compulsion before it’s too late). This fear is their Core Fear (for further discussion see Three Types of OCD Cases).
Rumination-Focused Conceptualization
What’s going on in these cases is that once the person experiences the urge, they immediately begin to ruminate about it. Specifically, they:
- Direct attention toward the urge, and
- Debate whether to gratify it.
Both of these forms of cognitive engagement with the urge actually perpetuate it. In other words, as long as the person keeps focusing on the urge and debating whether to gratify it, they continue to experience it.
These individuals are stuck because they don’t know how to stop ruminating. Once the urge arises and they start ruminating about it, there’s no way to make it go away other than to gratify it. Naturally, they often learn that it’s easiest to just get it over with, because they have no other way out.
Thus, their fear that the urge will never go away isn’t just hypothetical; it’s based on repeated lived experience.
In summary, people with this problem are trapped because, without knowing how to stop ruminating, there is no way out of the urge other than by gratifying it.
Rumination-Focused Treatment Plan
It follows from the above that the solution to this problem is twofold:
- To learn how to stop ruminating (i.e., how to cognitively disengage from the urge), and
- To learn that this can be used to make the urge go away.
This provides a way out of the urge other than gratifying it, and thus restores the person’s sense of control over the compulsive behavior.
The RF-ERP protocol for these cases is as follows:
- Teach the person how to stop ruminating (including how to disengage attention)
- Trigger the urge and show them that they can turn it off by not ruminating about it (i.e., not directing attention toward it and not debating whether to gratify it)
- Do things that trigger the urge in order to practice turning it off by not ruminating about it (these are the exposure exercises and can be done hierarchically)
Notably, in cases like these, doing exposures without teaching the person how to stop ruminating is of limited help because it doesn’t really address the problem.
Implications
I believe that cases labeled by some as ‘disgust-based OCD’ are more helpfully understood within this framework. That is, they are actually fear-based like all other types of OCD; the fear is the feeling of disgust never going away.
I also think it’s possible that this conceptualization might potentially collapse the distinction between ‘Tourettic OCD’ and tics. Indeed, my colleague Dr. Suzie Long has successfully applied the above approach to treating tics.
Finally, this conceptualization challenges the use of ‘urge surfing,’ because it suggests that directing attention to the urge actually perpetuates it.