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Maintenance of Obsessive-Compulsive and Related Disorders

Matthew D. Jacofsky, Psy.D., Melanie T. Santos, Psy.D., Sony Khemlani-Patel, Ph.D. & Fugen Neziroglu, Ph.D. of the Bio Behavioral Institute, edited by C. E. Zupanick, Psy.D.

In the beginning of this chapter, we set out to answer two questions: 1) What causes obsessive-compulsive and related disorders? and, 2) Why don't these folks just stop doing these things (hoarding, picking their skin, pulling their hair out, washing their hands, checking the locks, obsessing about their appearance)? In the previous section, we answered the first question using the biopsychosocial model to explain the many causes of these disorders. We now have a greater understanding of how these disorders were initially formed. However, this understanding does not explain why these disorders continue. We now turn our attention to this second question, "Why don't they just stop?"

hand holding stop signIn order to answer this question we need to understand a fundamental principle of learning called operant conditioning. Operant conditioning is founded upon some very basic common sense. Namely, when a behavior is rewarded it will continue, or increase. When a behavior is punished, it will diminish or discontinue entirely. However, what constitutes a reward may be less intuitive. The removal of an unpleasant consequence is rewarding. As such, the removal of an unpleasant consequence causes a behavior to be repeated, or increase. This is called negative reinforcement. As a silly example, suppose I am pinching you. If I stop every time you speak, and resume pinching you when you're quiet, you're going to start talking a whole lot! In other words, I negatively reinforced talking by removing pinching, so that behavior (talking) increased.

The concept of negative reinforcement is central to understanding why OCRDs continue. This may be more easily understood by using an example. Suppose a person with obsessive-compulsive disorder is exposed to an object they believe to be contaminated. They will experience a high degree of anxiety because of this exposure. By washing their hands, the anxiety goes away. Because washing their hands "took away" their anxiety, there is a high probability the individual will again wash their hands the next time they come in contact with a 'contaminated' object. In other words, they were negatively reinforced to wash their hands because it removed anxiety.

A similar process occurs with a protective coping strategy called anxious avoidance. This coping strategy refers to efforts to avoid anxiety-provoking situations at all costs. Avoidance behaviors are negatively reinforced because avoidance reduces anxiety. This coping strategy is commonly observed in people with hoarding disorder. For someone with this disorder, the prospect of cleaning up and disposing of excess possessions creates high degrees of anxiety. By avoiding the pile, the room, the person, or situation that caused them to confront the need to get rid of some things, anxiety is immediately reduced. Therefore, avoidance is rewarded. It will become a preferred means of coping with the distress caused by the mere prospect of getting rid of possessions. Unfortunately, if this person does not learn to face situations that create anxiety, and instead continues to avoid it, the hoarding behavior continues unchecked. The avoidance coping strategy serves to maintain the disorder because the person is never afforded the opportunity to learn that they can tolerate their anxiety. Likewise, they will not have opportunities to unlearn the faulty beliefs.

The good news is, anxiety to naturally subsides on its own (called habituation). However, people must allow themselves to face the anxiety-provoking situations in order for habituation to occur. This requires people stop avoiding stressful, anxiety-provoking situations and/or must NOT perform their compulsions. Without this type of exposure, OCRDs continue because there are no opportunities to master anxiety-provoking situations, and faulty beliefs cannot be corrected.