An involuntary thought of a sexual act with a coworker constantly repeats in your head, and you begin to rapidly recite poetry. The thought of a disease crawling across packaged meat causes you to wear gloves at the grocery store. Imagery of charred family members results in fire extinguishers in every room of the house. Forceful ideas about running people over make you avoid driving entirely. You game until 0400 to avoid being alone with your thoughts before bed. When using the restroom, you pick at your skin to avoid yourself.
The compulsive part of Obsessive-Compulsive Disorder refers to repetitive or ritualistic behaviors performed in response to intrusive thoughts with the false hope of eliminating them. Since OCD basses in intrusive-thought driven obsessions, compulsions form secondarily as a behavioral defense. Several different models explain how compulsions form, but today we’ll focus on the Behavioral Model of OCD. This theory posits that compulsions arise due to classical conditioning, and that operant conditioning reinforces and worsens these behaviors. Let’s explore how this model connects intrusions with activities ranging from reciting prayers to avoiding children to cutting.
Psychological Models of OCD
At least two models explain the workings of OCD: the Behavioral Model of OCD and the Cognitive Theory of OCD. Additionally, Acceptance and Commitment Therapy provides a treatment methodology, but is not itself an explanatory model. As mentioned above, we will only be discussing the Behavioral Model today. Chapter 12, “Psychological Models and Treatments of OCD for Adults,” of The Wiley Handbook of Obsessive Compulsive Disorders: Volume I explains these theories and therapies in detail with case studies for each. Much of the inspiration and information for this article comes from this chapter. Luckily, treatment based on these concepts are not mutually exclusive. For example, the Intensive Outpatient Program I attended utilized techniques from all three treatment models.
Many people have heard of Pavlov’s dog, the famous experiment demonstrating classical conditioning. In brief, Ivan Pavlov noticed that dogs didn’t just salivate at the sight of food, but also at the sight of the technician who fed them—regardless of if the technician had food. Importantly, an automatic process controls salivation, i.e., the dogs did not control the behavior. Ivan tested the hypothesis that uncontrollable behaviors can associate with a stimulus that precedes a reward by playing a metronome before feeding the animals. Eventually, the dogs began to salivate simply at the sound of the metronome. The animals involuntarily learned to react to a new stimulus. Classical conditioning explains numerous animal behaviors, including OCD compulsions.
The following terms define the components of classical conditioning. Let’s both define them and use Pavlov’s dogs example to clarify the terms. These terms will appear later in the article.
Unconditioned stimulus: something we respond to automatically, e.g. dog food
Unconditioned response: the automatic response to the unconditioned stimulus, e.g. salivating
Neutral stimulus: some stimulus that does not result in the unconditioned response, e.g. the metronome
Conditioned stimulus: the neutral stimulus after it has been paired with the unconditioned response, e.g. the metronome
Conditioned response: the response to the conditioned stimulus, e.g. salivation
We react instinctively to acute stress: we have little-to-no conscious control over our immediate stress response. When a new an immediate threat presents itself, the fight-flight-freeze response activates. During this response, the autonomic nervous system creates a massive physiological shift and initiates instinctive behaviors. By utilizing instinctive reactions, the brain can respond much more quickly to a threat than if it resorted to conscious processes. Any form of acute stress induces a fight-flight-freeze response, and the exact response varies based on the individual and situation. However, if the threat persists, chronic stress and anxiety may develop.
Intrusions interrupt a sufferer’s thoughts at such a high rate that they become paired with anxiety. Some of the worst intrusive thoughts and images include sexually abusing children, accidentally or intentionally killing people around you, becoming diseased and harming others, questioning your worth and existence, and betraying friends and family. All of these actions representing threatening situations and can elicit an autonomic response; the thoughts themselves do not constitute a danger. While everyone has intrusive thoughts, the high rate of them in people with OCD causes them to occur before almost anything anxiety-inducing. This pattern—intrusion-event-anxiety—causes conditions the brain to associate intrusive thoughts with anxiety. Furthermore, due to high Thought-Action Fusion (TAF) associated with OCD, some of these thoughts will directly lead to disquietude. For example, intrusive thoughts about molesting children become either equivalent to actually molesting a child (TAF) or proof that one will molest a child in the future in the mind of a sufferer. The perpetual tide of intrusive thought produces continual agita, the perfect environment for the genesis of new compulsions.
OCD and Classical Terminology
Let’s explicitly construct the previous paragraph in classical conditioning terms. The unconditioned response is anxiety after a failed fight-flight-freeze response. The unconditioned stimulus is literally anything that results in anxiety. Intrusions constitute neutral stimuli. After intrusive thoughts become paired with anxiety, intrusions are now the conditioned stimulus and anxiety is the conditioned response.
Attempts to eliminate anxiety spawn compulsions. When experiencing apprehension, any distracting action will temporarily reduce stress. Since we naturally take actions to combat our perceived threats, the behaviors we perform will typically relate to the perceived threat. For example, if you believe you will run some over while driving to work, you may take a slower, alternate route or constantly check your speed. While checking the speed, your stress momentarily drops as you focus on reading the dial. As another example, if you fear intrusive thoughts of sex with strangers, you may not leave your place at all. Since you have avoided the perceived threat, your stress may diminish—you now feel compelled to avoid all public contact. However, none of these actions resolve the perceived threat, as it isn’t real in the first place; the anxiety relief truly is only short-term as the agita will still be there when the compulsion ends. Now that we’ve established a behavior, operant conditioning reinforces it.
Operant conditioning enforces and aggravates compulsive behaviors—sometimes also called safety behaviors as they give the illusion of security. Classical conditioning explains how a neutral stimulus becomes associated with an automatic response. Pavlov’s dogs cannot choose whether or not to salivate in the presence of food. Similarly, the learning process does not require conscious interaction: we do not choose whether to condition a stimulus and response. Contrarily, operant conditioning describes how conscious reactions to stimuli result in the modification of behavior. Let’s dive further into operant conditioning before addressing its impact on OCD.
While Edward Thorndike described operant conditioning—albeit the term hadn’t been coined yet—via the law of effect in 1898, B. F. Skinner truly fathered the theory by studying observable behaviors in rigorous experiments. Among several famous experiments, Skinner studied how rats learned to press a lever to obtain food or avoid an electric shock. In one set of trials, Skinner placed hungry rats in a box with a lever. When the rats depressed the lever, it received food from a dispenser. The rats quickly learned to obtain food from the device and would do so until full, and then return whenever it became hungry. In the second set of experiments, an electric grid in the box produced an uncomfortable current. The rats began to run around the box to avoid the shock until they accidentally bumped into the switch. When flipped, the lever shut off the current. Before long, the rats would run directly to the switch when placed in the box. While these experiments provided different incentives for the rats, both resulted in an increased pressing of the lever.
Both obtaining rewards and avoiding negative outcomes increase the frequency of a behavior. In the case above, the rats depressed the lever to either gain an appetitive stimulus (food) or avoid a noxious stimulus (electric current). We refer to the prior as positive reinforcement and the latter as negative reinforcement. Negative reinforcement also separates into escape learning and active avoidance. Both forms of negative reinforcement involve a noxious stimulant, but escape learning involves removing the stimulus, while active avoidance refers to avoiding the stimulus altogether. Note that all the behavioral categories above involve choice: you choose to gain the reward, remove the unfavorable stimulus, or avoid the adverse stimulus.
Operant conditioning also explains how to decrease behavior through positive punishment and negative punishment, but they will not be relevant to our discussion today.
The Sun in Your Eyes: Escape Learning and Active Avoidance
When you are in bright sunlight, your eyes hurt and your vision is impaired. The sunlight is the noxious stimulant. You instinctively squint—an automatic response—but the sun still mars your eyesight. If you shield your eyes with your hand, a voluntary action, the effect of the sun is reduced. The noxious stimulant has been removed and you’ve learned to protect your eyes from the sun with your hand in the future, i.e. you’ve learned to escape the noxious stimulant. Alternatively, you could choose to never enter bright sunlight, i.e. you begin to actively avoid intense light.
Negative reinforcement increases the rate and severity of compulsions. As previously established, safety behaviors originate because they temporarily alleviate anxiety—the noxious stimulant. When performing a safety behavior requiring active involvement, like scrubbing down walls or pulling out hair, a sufferer momentarily escapes anxiety as their focus shifts to the behavior. Many sufferers also actively avoid situations where they’ve experienced high stress or anxiety before. Though these behaviors do not remove the threat, as mentioned above, they mitigate the fear long enough to fulfill negative reinforcement requirements. Now operant conditioning has reinforced compulsive/safety behaviors, sufferers may perform said behaviors at an increased rate and for increasingly longer periods—depending on current their current stressors.
In regards to OCD, active avoidance is often called primary avoidance while escape is typically called secondary avoidance. The names simply refer to people first wanting to avoid a situation that may trigger obsessions, and then having to find alternative means to avoid intrusions when forced into such a situation.
Note that I didn’t use the word OCD once in the last paragraph (not counting the highlight). Many disorders can result in compulsive responses to anxiety and triggers—such as OCPD and autism—and operant conditioning principles apply to all of them. Note that some disorders may have compulsions unrelated to anxiety, and operant conditioning may not apply to these cases. Refer to the figure near the beginning of the article. In the general case, negative reinforcement connects “short-term anxiety reduction” to “anxiety response.” If we’ve learned to perform safety behaviors to lessen anxiety, then the cycle becomes anxiety-compulsion-temporary relief repeated until the anxiety has naturally passed with time. In effect, this cycle acts as a distraction to mitigate fear until the agita has passed.
However, OCD draws the arrow from “short-term anxiety reduction” to “obsessional fear.” When intrusive thoughts have become the source of anxiety, due to classical conditioning, you perform compulsions that attempt to combat the obsession itself. As a result, your compulsive behaviors remind you of the initial intrusion and elicit more fear. Since negative reinforcement has taught you to perform compulsions in response to the anxiety, you repeat the process: intrusion-anxiety-compulsion-temporary relief-intrusion ad nauseam. Paradoxically, OCD compulsions don’t provide an unhealthy distraction from agitation but turn the process into a positive feedback loop that generates anxiety.
Treatment and Conclusion
While the following information about treatment comes from some academic literature, in addition to my personal treatment, I believe it necessary to remind everyone of my disclaimer: I am not a medical professional, please defer to your healthcare provider for medical advice. Ultimately all thoughts expressed herein are my own interpretations and understanding of OCD.
I introduced many terms in this article, so lets quickly recap the behavioral model of OCD sans-jargon. When anxiety-inducing events occur after intrusive thoughts multiple times, intrusions pair with anxiety directly. In response to the stress, sufferers perform compulsions, which temporarily alleviates anxiety. This relief teaches people to continually perform neutralizing behaviors to ineffectively escape agita. Because the compulsions relate to the intrusions, they can re-trigger the initial thoughts and start the cycle anew.
Since operant conditioning requires voluntary behaviors, are compulsions not voluntary? Further, can’t the cycle break by just not performing compulsions? Well, yes, kind of, sort, but it typically requires professional help. By its very definition, the word compel means to force a course of action. Since safety behaviors may lead to more intrusive thoughts, they do not always provide sufficient anxiety relief to constitute successful avoidance/removal of a noxious stimulant. We can say that the reinforcement occurs after variable number of intrusive events. This is know as a variable ratio schedule (yup, throwing in more argot) and results in the highest rate of response and is very resistant to extinction—the process of a behavior reducing after it is no longer reinforced.
Reducing or removing compulsions can slow or stop the cycle, but requires specific forms of treatment. Exposure and Response Prevention (ERP) consists of exposing people with OCD to their obsessional fears and having them resist and sometimes fully eliminate their compulsive response. This process takes a long time and requires starting with portions of an obsession that build toward the core fear. However, the Inhibitory Learning Model of ERP has proven very effective in reducing OCD symptoms. Inhibitory learning works by re-associating intrusive thoughts with non-threatening alternatives. For example, when you have a thought about stabbing someone with a knife, inhibitory learning trains you to think “thoughts about stabbing someone are acceptable” instead of “thoughts about stabbing someone are terrible, and I am terrible.” A critical aside: note that this therapy works with OCD intrusions that are unwanted thoughts, not genuine ideations or desires—learning that “thoughts about stabbing someone are acceptable” refers to the intrusion, not that planning to stab people is acceptable (I argue that someone with OCD is just about the last person you’d expect to harm someone). By redirecting intrusive thoughts to non-anxiety-inducing ends, inhibitory learning breaks the classical pairing of unwanted thoughts and images to anxiety. Finally, by learning how to handle anxiety and preventing compulsive behaviors, the connection between safety behaviors and anxiety relief extinguishes.
OCD compulsions are the result of innate learning behaviors applied to abnormal psychiatric functions. Behavioral learning theories satisfactorily explain how compulsive behaviors run the gamut from biting one’s nails to dressing “overly modestly” to self-bruising. These “safety” behaviors can escalate to extremes, cause constant terror, and consume many hours of each day if left untreated. Fortunately, the models explaining compulsive behavior also offer therapies to treat them. By understanding how compulsions form, we can consciously subvert the cycle and reclaim our lives.
Have a great day and always practice self-compassion!A Fantastic Friend of Mine