Mental compulsions can be tricky to identify and treat. Why? They are invisible and can often be mistaken for obsessions. A good eye can catch this though and a solid way to begin is to throw the idea that there are solely obsessions and no compulsions out the window. Most experts agree that there are both obsessions and compulsions although the DSM specifies there can be obsessions, compulsions, or both. Research suggests pure obsessional type OCD is a myth. One study used factor analysis to prove that patients in the sample with obsessions also had compulsions that were factorially associated with mental compulsions and reassurance-seeking (Williams et al., 2011). Obsessions and compulsions characterize OCD. Obsessions are those intrusive, often unexpected, involuntary thoughts. Compulsions, which can be thoughts too, are things under the client’s control and used to decrease the anxiety or disgust that the obsession causes them. OCD can be purely mental, but there are always obsessions and compulsions. Without the compulsions, the sufferer may have generalized anxiety, possibly a phobia but that's up for differential diagnosis debate. The point is that mental compulsions are voluntary and occur in response to the obsession, and the obsession is involuntary and intrusive. Compulsions maintain the OCD cycle by temporarily relieving anxiety symptoms and this interferes with a client’s ability to disconfirm their fears or beliefs.
It may feel like the obsessions and compulsions cannot be controlled. While the obsessions are intrusive and unwanted, the compulsions can be controlled. Although that’s not what OCD wants people to believe. Because the anxiety is so intense, it makes one feel like they have to do this compulsion, which complicates distinguishing obsessions from mental compulsions. So for clients, what often feels involuntary is voluntary. Clinicians must help clients differentiate between obsessions and compulsions, while also validating the complexity of this task.
Mental compulsions may look like this:
- Compulsively trying to figure things out or figure out their meaning
- Ruminating
- Replaying past conversations or mentally reviewing past situations
- Saying words, numbers or phrases
- Counting words, letters, syllables, numbers, or objects
- Repeating making lists or categories
- Replacing an obsession with a different image or word
- Compulsively saying prayers
- Scanning sensations, emotions or reactions
- Dissecting and scrutinizing past situations with potential what-if scenarios
- Anticipating future situations with or without potential what-if scenarios
- Compulsively trying to figure out major life issues or existential matters (ACT Beyond OCD, n.d.)
- Self-reassurance
These are done in an effort to reduce anxiety, occur repeatedly, and make clients feel compelled or strongly urged to do them. This makes compulsions feel involuntary to the client, but remember they are in actuality in the client's control. While we all ruminate at times, OCD is a mental health diagnosis that is time-consuming and impacts a person’s ability to function at places like work, home, or school.
Some Examples
Kara's OCD tells her “What if you hit someone with your car and don’t know it?” As a result, she ruminates for hours trying to replay the scenes from driving that day to figure out if she hit someone. Her anxiety is reduced until the next day when she drives again, she does this cycle all over again. If Kara compulsively drove around the scene to make sure, this would be considered a physical compulsion and is a more pronounced behavior. Because she is mentally reviewing to make sure (to reduce her anxiety) she did not hit anyone she is doing mental compulsions. Some clients don’t even realize they are doing this or have trouble describing it. This can show up differently for anyone suffering from OCD. For example, Kara may have been doing physical compulsions (checking the scene, reading recent crash reports, etc.) and then stopped those and began doing the mental compulsions. It could be that she does both. In that case, treatment would involve addressing both compulsions. Leaving mental compulsions untreated will only grow the OCD and are just as bothersome as the more obvious compulsions.
Treatment
Mental compulsions can be treated through a treatment known as Exposure and Response Prevention (ERP). In this therapy, patients will learn to sit with the anxiety from obsessions and refrain from compulsions. A trained clinician will help them tolerate the uncomfortable feelings gradually, ultimately rewiring the brain to learn new things about the feared situation. ERP is based on the idea that facing your anxiety repeatedly for a prolonged period of time (enough time to see your anxiety decrease) is the best way to treat your OCD. Continuing to engage in compulsions only strengthens the OCD. For this reason, it is crucial to differentiate compulsion from obsession. Patients will be activating and welcoming the obsession (fear) through exposures but refrain from compulsion (behavior). Clinicians will also help patients understand why they feel compelled to perform the compulsions. ERP has been found to work for 80% of people with OCD, and most people will experience results within 12-25 sessions (Quick, 2022). Your ERP therapist will also help you rank your feared situations and approach them in a way that is not too overwhelming. If you find that you are “white knuckling” it through the exposures, that is a sign you may be moving too fast. This is why it is essential to work with a therapist that is specially trained in ERP and can give you best practices and support.
At Cognitive Behavior Institute, our therapists receive specialized training and have access to guidance from clinically competent ERP professionals. Our therapists can help you gain control of your life again by exploring your goals and creating a tailored plan to guide you to relief. We know that every client has a unique struggle.
If you or a loved one are suffering from OCD or are unsure and are seeking help, call us to schedule with one of our clinicians that specializes in OCD treatment at 724-609-5002 or fill out a new patient form here.
If you are a professional interested in EXRP (ERP) training join us for this training 4-Day Intensive Workshop: Exposure and Response Prevention Therapy for OCD
References
ACT Beyond OCD. (n.d.). Types of Mental Compulsions. ACT Beyond OCD. https://www.actbeyondocd.com/types-of-mental-compulsions/
Quick, S. (2022, July 27). Mental Compulsions: The Unseen Battle. NOCD. https://www.treatmyocd.com/blog/mental-compulsions-the-unseen-battle
Williams, M., Farris, S., Turkheimer, E., Pinto, A., Ozanick, K., Franklin, M., Liebowitz, M., Simpson, H., & Foa, E. (2011). Myth of the pure obsessional type in obsessive--compulsive disorder. Depress Anxiety. 28(6):495-500. doi: 10.1002/da.20820
