Interview with Idoia Castro: OCD from the point of view of a psychologist

Obsessive-Compulsive Disorder (OCD) is much more than what you see in the movies.

The Obsessive-Compulsive Disorder (OCD) is one of the most talked about psychological disorders, both in everyday conversations and in cultural products: series, books, movies, etc.

It has gained a reputation as a curious, attention-grabbing phenomenon that expresses striking personality traits that are sometimes portrayed as a form of charisma: obsession with order, the desire for everything to go according to plan and to go according to plan, etc. However, the real OCD, the one that really exists, is much more complex than that, and can greatly damage the quality of life of people. That is why it must be treated by specialists.

On this occasion we interviewed one of those people who are experts in intervening in patients with problems such as Obsessive-Compulsive Disorder: the psychotherapist Idoia Castro Ugalde, Director of the Bilbao psychology center Abra Psicólogos. Idoia Castro Ugalde, Director of the psychology center Abra Psicólogos in Bilbao..

Interview with Idoia Castro: understanding Obsessive-Compulsive Disorder beyond the clichés

Idoia Castro Ugalde is a psychologist specialized in the clinical and health field, and has been working in the world of psychotherapy for more than 20 years. On this occasion she talks to us about Obsessive-Compulsive Disorder from the point of view of someone who, as a professional, has helped many people to face this psychological disorder and overcome it.

What exactly is OCD?

Obsessive-compulsive disorder (OCD) is characterized by the presence of obsessions and/or compulsions.

Obsessions are recurrent and persistent thoughts, impulses or images that are experienced, at some point in the disorder, as intrusive and unwanted and that in most people cause a significant degree of anxiety or discomfort.

The compulsions are behaviors or mental acts, of ritual and repetitive type that the person realizes as answer to the obsession, or in agreement with rules that "it has to apply" of a rigid form. The aim of compulsions is to prevent or reduce anxiety or discomfort (caused by the obsession), or to avoid some feared event or situation; however, these behaviors or mental acts are not realistically connected with those that would be intended to neutralize or prevent them, or are clearly excessive.

Obsessions or compulsions are time consuming and cause clinically significant distress or impairment in the social, occupational or other important areas of functioning of the sufferer.

The content of obsessions and compulsions varies from one individual to another. Among the most frequent are contents related to cleanliness (contamination obsessions and cleaning compulsions), symmetry (obsession with symmetry and repetition, counting and ordering compulsions), taboo thoughts (aggressive, sexual and religious obsessions and related compulsions) and harm (fear of harming oneself or others and checking compulsions). Other people have difficulty discarding things and hoard objects.

It is common for people to have symptoms in more than one dimension.

Does it have any relation to what is known as "magical thinking"?

Superstition has been related over the years to various psychological disorders.

The concept of "magical thinking" can be considered as the most widely used within cognitive psychology to refer to superstitious thoughts. It would be a type of cognitive distortion. Specifically, through magical thinking the person makes a causal attribution of the influence that an event has on actions or thoughts when in fact, there is no such causal relationship.

Superstitious beliefs are a type of "magical thinking" that has been transmitted from generation to generation and are generally associated with good or bad luck, for example, "the bad luck that a black cat crossing our path can bring us".

Magical thinking" in a non-clinical setting is part of the normal development of children up to about 10 years of age (at which time they begin to distinguish between reality and fantasy), in "primitive" societies and minimally in Western societies, related to uncertainty or lack of knowledge to explain certain issues.

In both children and adults, "magical thinking" plays a relevant role in OCD. To a large extent, this differentiates it from other types of anxiety disorders and it seems that a high level of magical thinking is related to a worse prognosis of the disorder. The person with OCD may believe that performing a particular mental or behavioral ritual (compulsion) will prevent the disaster he or she fears from occurring (obsession).

Individuals with OCD vary in the degree to which they are aware of the accuracy of the beliefs that underlie their obsessive-compulsive symptomatology. Many people recognize that these beliefs are clearly or very probably not true; others consider them to be probably true; and some people are completely convinced that the OCD-related beliefs are true. The latter case, in which the person has little or no awareness of illness, and believes with great conviction the content of his or her magical thinking, may be linked to a worse long-term course of OCD.

Is there a profile of a person with a higher propensity to develop Obsessive-Compulsive Disorder?

To date, we do not know the exact causes of OCD. There are a number of factors under study, which seem to influence its onset.

Environmental factors could include head injuries, infectious processes and autoimmune syndromes, the fact of having been physically or sexually abused in childhood and stress.

In the socio-environmental factors there are certain educational styles that encourage hyper-responsibility and perfectionism, a rigid moral or religious formation, an overprotective educational style, parental models with behaviors with low tolerance to uncertainty, excessive importance of the relationship between beliefs that overestimate the importance of thinking and responsibility or involvement of one's own identity in what is thought (e.g. "thinking something bad is the same as doing it") and/or exaggerate the connection between thought and reality in what has been called "thought-action fusion" (e.g. "thinking something can make it happen").

There are also temperamental factors: internalizing symptoms, increased negative emotionality and behavioral inhibition in childhood.

As for genetic factors, the likelihood of having OCD among first-degree relatives of adults with the disorder is about twice as high as among those who do not have first-degree relatives with OCD. than among those who do not have first-degree relatives with OCD. In cases of first-degree relatives with childhood-onset OCD, the rate increases 10-fold.

In neurophysiological factors there are dysfunctions of certain cortical areas of the brain that seem to be strongly implicated.

Finally, as neurochemical factors, the hypothesis that has more scientific support is the serotonergic one.

Bearing in mind that psychological disorders often overlap with each other, what are the mental disorders that usually go hand in hand with OCD?

Many people with OCD also have other psychopathologies.

According to the American Psychiatric Association (APA) in its Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 76% of adults with OCD are also diagnosed with an anxiety disorder (panic disorder, social anxiety, generalized anxiety or specific phobia) or 63% have another diagnosis of depressive or bipolar disorder (major depressive disorder being the most common). The onset of OCD is usually later than that of comorbid anxiety disorders, but often precedes depressive disorders.

Obsessive-compulsive personality disorder is also common in people with OCD, approximately 20-30%.

The tic disorder appears in up to 30% throughout the life of people with OCD, and in children the triad composed by OCD, tic disorder and attention deficit/hyperactivity disorder can be seen.

Certain disorders such as body dysmorphic disorder, trichotillomania (hair pulling), excoriation disorder (skin scratching) and oppositional defiant disorder also occur more frequently in people with OCD than in people without OCD.

Finally, in people with certain disorders the prevalence of OCD is much higher than in the general population, so when one of these disorders is diagnosed, one should also assess for OCD. For example, in patients with certain psychotic disorders, eating disorders and Tourette's disorder.

As a professional, what strategies do you usually use to intervene in patients with this psychological disorder?

Currently, and since the emergence of "third generation therapies" such as Acceptance and Commitment Therapy (ACT) and Mindfulness, I use an integrative intervention for the treatment of OCD, complementing Cognitive-Behavioral Therapy (CBT) with these new techniques.

Cognitive-behavioral therapy tries to solve psychological problems and suffering, based on the relationship between feelings, thoughts and behaviors. We know that most people sometimes have negative thoughts, or intrusive thoughts that appear automatically in our mind. CBT teaches us to identify this type of negative thoughts, and to change them for other rational thoughts, which adjust to reality. Thus, through cognitive restructuring we can cope with our lives in a more adaptive and realistic way.

With regard to OCD, it is important to differentiate between normal intrusive thoughts and obsessive thoughts, which can be defined as negatively appraised and biased intrusions.

When these normal intrusive thoughts are negatively and catastrophically appraised, the person begins to experience an elevated level of anxiety and worry, and interprets the intrusive thoughts as if they are serious, dangerous and need to be dealt with. The compulsions characteristic of OCD have the effect of neutralizing the worry and relieving the anxiety caused by the obsession. In this way the ritual behavior (compulsion) is negatively reinforced and the disorder is consolidated.

In therapy, we teach patients to identify their own intrusive thoughts, to work with them and provide them with the most effective cognitive and behavioral tools, depending on their idiosyncrasies.

Acceptance and Commitment Therapy tries to change the relationship that the person has with his or her own symptoms. They have to do something that probably goes against their common sense, such as "accepting" the symptoms instead of trying to "eliminate" them. The first step in dealing with obsessions and compulsions is to "accept" them, rather than resist or fight them.

As noted above, there is a high coexistence of obsessive-compulsive symptomatology with other disorders, such as depressive disorders and other anxiety disorders.

In this case, ACT applied in a complementary manner to cognitive-behavioral therapy is aimed at improving some of the symptoms derived from associated disorders such as depression and anxiety (as these cause the symptoms of OCD to increase or become more complicated), making it possible to reduce the frequency of intrusions and ruminations, and to reduce the level of anxiety caused by OCD.

The treatment is carried out individually, according to the needs and idiosyncrasies of each patient and in some cases when necessary, it is combined with psychopharmacological treatment, under medical prescription.

Early psychotherapeutic intervention is essential in patients with OCD, to avoid chronification of the disorder, since without treatment remission rates are low.

How is the recovery process in which the patient overcomes the disorder?

Treatment using CBT, ACT and Mindfulness, addresses obsessions and compulsions with various cognitive and behavioral techniques, such as cognitive restructuring, exposure with response prevention, acceptance of certain symptoms, and management of relaxation techniques, among others.

Learning these techniques equips patients to be able to manage OCD symptoms should they recur at some point in the future. Post-treatment results generally show a significant decrease in anxiety levels and experienced discomfort and the reincorporation of the person to the important areas of functioning of his or her life.

It is important to emphasize the importance of motivation and collaboration on the part of the patient, both to attend the sessions and to carry out the homework that the patient is asked to do as personal work, outside the consultation sessions. This is fundamental for the success of the treatment, as is the participation, collaboration and support of significant people in the patient's environment (partner, family, friends).

Finally, once the treatment itself has been completed, we consider it important to carry out follow-up and relapse prevention sessions.