Compulsion

DSM-5's Compulsion Definition

The final requirement for OCD Opens in new window is that obsessions Opens in new window cause compulsions.

Compulsive behavior may be attributable to obsessional ideas. For example, a young adult may become obsessed with the idea that his shoelaces must be perfectly tied, continually retying them for twenty minutes, and unable to move on to the next stage of dressing until this objective has been achieved; or he may continually close the refrigerator door until it eventually makes the “right” sound.

DSM-5 (p. 237) defines a compulsion as:

• Repetitive behaviors (e.g., handwashing, ordering, and checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

• The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

As presented, it sounds as if anxiety or an anxious thought causes the compulsion, but how they do so is complicated. The ways that people respond to anxiety vary, even in non-pathological cases.

People vary in what sorts of things they think will soothe their anxiety. Some anxious people will repetitively wash and others will repeat phrases to themselves.

Both of those compulsions could come from anxiety about cleanliness and contamination. So already we see that the story is not a simple one that can predict how or whether anxiety will result in compulsion.

Compulsive Acts and Obsessive Thoughts

It can be seen that the terms obsession Opens in new window and compulsion are not synonymous. The former refers to a thought and the latter to an act.

Obsessions are recurrent, persistent ideas, thoughts, images, or impulses that are not experienced as voluntarily produced but as ideas, urges or representations which invade consciousness.

A thought may properly be described as obsessional if a person cannot prevent himself from repeatedly, insistently, having that thought albeit that the content of the thought is not delusional Opens in new window in nature.

Obsessive thoughts lie behind compulsive acts, and stereotyped or manneristic behavior, but they may exist without being externally manifested in the form of an observable repetitive action.

What we can say as a generalization, though, is that compulsions, like obsessions, are unjustified. Obsessions can reduce anxiety Opens in new window in the short term, so they are justified in that way. But they lack a realistic, proportionate connection to reducing one’s anxiety overall; and worse, they serve to reinforce the anxiety. So they end up being counterproductive.

This makes it especially strange that people continue to have compulsions. Checking the lock on my door makes sense if it’s a sticky lock that sometimes doesn’t shut correctly, but how does one develop a lock-checking compulsion when the lock has never failed?

If compulsions worked overall, it would make sense that anxious people have them. So how do they arise and why do they stick around?

The key to understanding this is that a compulsion did, at one point, reduce anxiety for the person. It has the opposite effect, of increasing anxiety, only over time. Let’s see how that might develop in a case of lock-checking OCD.

An obsessive thought of a break-in evokes (or legitimates, or makes sense of) anxiety, and the person discovers that checking the lock temporarily reassures him and soothes the anxiety. The connection between the worry and the soothing checking behavior is straightforward and reasonable.

This reassurance is brief, however if his underlying anxiety about the house’s security—or perhaps a more general anxiety—returns, or even persists through, the checking; the obsessive thought will return.

When it returns, with the attendant anxiety, this leads to more compulsive behavior in an attempt again to soothe the anxiety. But it turns out that this will develop into an especially vicious circle in the person with OCD Opens in new window.

To complicate our lock-checking example, the more often this routine occurs, the more, well, routine it feels to check the lock in response to feeling anxiety. And this also makes the routine feel less assuring.

If the initial routine fails to soothe the anxiety, then these individuals may develop compulsive rituals that are less reasonably responsive to the initial anxiety:

• They develop a particular way of checking the lock that feels more reassuring.
• They check it a certain number of times or while holding a certain neutralizing thought in mind.
• Or they develop the belief that the house will remain secure if they always lead with the right foot when stepping into the house or never touch the doorknob with the left hand.

These more complex compulsions turn the checking, which initially responded (albeit excessively) to a specific anxiety about the vulnerability of the house, into a ritual that is more than just a temporary reassurance that the lock remains locked.

Indeed, the individuals might perform some compulsive lock-checking ritual as a way of staving off anxiety before any anxiety is felt (Salkovskis, 1999). When they walk near the front door, they check its lock just in case, though not in response to any felt anxiety about a break-in.

Or they engage in other compulsions, such as strenuously avoiding vulnerable parts of the house, or seeking excessive reassurance from locksmiths or security companies that the house is secure from break-in.

At this point, the ritual takes on a life of its own and becomes increasingly divorced from the initial anxiety that might have led to it. The result is a clear case of OCD Opens in new window.