Download Obssessive compulsive disorder (OCD) is considered among the

OBSESSIVE-COMPULSIVE DISORDER AND HYPNOSIS
Tahir Özakkaş MD., PhD
Ahmet Çorak MD.
Psychotherapy Institute İstanbul
Obssessive compulsive disorder (OCD) is considered among the anxiety disorders, and is defined
by recurrent, persistent obsessions and compulsions. Compulsions are inflexible because they are
produced to reduce severe anxiety, without which the patients may become severely terrified.
Although obsessions are mostly ideational and compulsions are motor, ‘motor obsessions’ and
‘ideational compulsions’ are not rare. Prevalance of OCD is 2.5 %, which makes it fourth most
common psychiatric disorder. OCD causes professional and social devastations in 20 % of the
patients in which obsessions and compulsions can occupy the whole day.
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM IVTR), the criteria for OCD are as follows;
A. Either obsessions or compulsions.
PSYCHOTHERAPY
OF
PANIC DISORDER
AND
HYPNOSIS
Tahir Özakkaş MD.,PhD
Psychotherapy Institute 2008
İstanbul/Turkey
19.09.2008 Wien
Psychotherapy Institute
İstanbul/Turkey 2008
Obsessions are
defined by (1), (2), (3), and (4):
(1) repetitive and persistent thoughts, images or impulses that are experienced, at some
point, as intrusive and inappropriate and that cause marked anxiety or distress
(2) the thoughts, images or impulses are not worries about real-life problems
(3) the person tries to ignore or suppress the thoughts, images or impulses, or neutralize
them with some other thought or action
(4) the thoughts, images or impulses are recognized as a product of one's own mind and
not imposed from without
Compulsions are defined as (1) and (2):
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(1) repetitive behaviors or mental acts that one feels driven to perform in response to an
obsession or according to certain rules
(2) the behaviors or mental acts are aimed at preventing or reducing distress or preventing
feared consequences; however the behaviors or mental acts are clearly excessive or are not
connected in a realistic way with what they are designed to neutralize or prevent.
B. At some point during the disorder the person has recognized that the obsessions or compulsions
are excessive or unreasonable.
C. The obsessions or compulsions cause marked distress, are time-consuming (take more than 1
hour a day), or significantly interfere with usual daily functioning.
D. The content of the obsessions or compulsions is not better accounted for by another Axis I
disorder, if present. (e.g., concern with appearance in the presence of Body Dysmorphic
Disorder, or preoccupation with having a serious illness in the presence of hypochondriasis).
E. Symptoms are not due to the direct physiological effects of a substance or a general medical
There is already convincing evidence in the literature that OCD is not a unitary syndrome, but
heterogeneous both in terms of symptoms and probably in terms of etiology. Thus, an integrative
approach is necessary for OCD.
When considered through an integrative approach, OCD may develop from a behaviorial way,
i.e., modelling, social learning, etc, or arise from cognitive schemas. OCD may be involved in
magical thinking, a rudimentary style remained from early childhood. This occurs when impulses
and actions are incompletely differentiated. Psychodynamically, OCD may develop from an
unresolved oedipal/electral complex, or as an ‘undoing’ mechanism of defense urged by superego
against an unconscious phantasy, or as a ‘reaction-formation’ defended against unconscious
chaotical state, or as a measure taken by the patient against potential loss of control especially
with respect to contamination, aggresion, and shame. OCD may be an existential defense against
feelings of emptyness, nihilism, meaninglessness, fear of death, etc.
Hypnosis is a social interaction in which one person (the subject) responds to suggestions given
by another person (the hypnotist) for imaginative experiences involving alterations in perception,
memory, and the voluntary control of action. Hipnotically embedded thoughts are on the border of
delusion, hypnotically induced behavior are compulsory. When hypnotically induced behavior is
prevented from being carried out, anxiety develops, as occurs in OCD.
According to the integrative approach, after a firm diagnosis of the etiyological cause, hypnosis
can be used in the treatment of OCD.
Behavioral models consider OCD as conditioned fear reactions that cause avoidance. Cleansing
behavior, in this regard, is considered as active avoidance, whereas, refusing to touch at so-called
‘contaminated’ objects as a passive avoidance. Because compulsive behavior results in reduced
anxiety, compulsions are reinforced
The early behavioral approaches employed thought-stopping as a direct intervention
to reduce obsessional thinking. Prolonged exposure to the obsession with instructions to refrain
from neutralization might be an effective intervention for obsessional phenomena.
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Exposure therapy is a key ingredient of behavioral approach. During exposure sessions, the
patient is expected to remain in an anxiety-provoking situation despite great distress. Through a
physiological mechanism, called habituation, anxiety is expected to be mitigated (desensitization
through extinction). Via using hypnosis, ‘almost in vivo’ exposure can be possible through ‘as-ifreal’ hypnotic scenes. For the therapeutical cause, patients must fully experience exposure
anxiety, that is always not possible. Under hypnosis, subtle avoidance can easily be uncovered.
Patients with social anxiety, or social phobia, pay attention to internal sensations in order to avoid
experiencing anxiety-provoking situation in the sessions fully, distancing themselves, and
discounting the experience as artificial. This weakens the effectiveness of exposure experience.
Under the hypnotic trance, patients are more under control, and are expected more readily to
experience such anxiety-provoking situations thoroughly.
Exposure in behavioral therapy uses role playing and imagination / visualization (in vitro
exposure), only homeworks are involved in real situations (in vivo exposure). However, a highly
hypnotizable subject can experience anxiety-provoking situation as if real. Even physiological
responses accompany to his/her emotions, hence, in vivo exposure is possible even in-session
tryouts.
By using hypnodrama, social learning or modelling can be reversed, or exposure treatment in
vivo can be applied.
Anxiety response is counterconditioned with a relaxation response or competing enjoyable
activity. There is a reciprocal inhibition between anxiety and relaxation conditioning.
Counterconditioning stimulus must be more powerful than the anxiety it is meant to inhibit.
During desensitization, patients are under undue stress, they may feel ill, or exhausted.
Suggestions in this case will be more effective under hypnotic state.
Breathing exercises under hypnosis can be done. Deep breathing activates parasympathetic
nervous system, hence, reduces anxiety.
Cognitive approach sees OCD as a result of dysfunctional cognitions. Obsessional beliefs can be
overestimation of threat (contamination fears, cleansing behaviors), intolerance of uncertainty,
importance of thoughts, need to control thoughts, responsibility, and perfectionism. Cognitive
approach targets the distorted thoughts associated with anxiety, followed by the behavioral
avoidance. Anxiety-producing cognitive distortions causes the patient to overestimate the risk.
Accordingly, patient catastrophize the situations that contain this risk. Person avoids from the
situation. As s/he avoids, his/her anxiety decreases. This reinforces further avoidance and
cognitive distortion.
Negative automatic thought preceded obsessions, myths, cognitive distortions can be uncovered
under hypnotic state. Hypnodramas directed to change the effects of myths or cognitive
distortions on the individual can be used. Cognitive restructuring of cognitive distortions can be
made more effectively under hypnotic state.
A dissociation between coping self and anxious self can be made. Cognitive distortions, also
called as poisonous thoughts, or paracytic thoughts, that produce anxiety are attributed to anxious
self, whereas, rational, accurate thoughts (antidote) are attributed to coping self. There are a wide
variety of hypnodrama scenes on which these two selves are meeting each other and are
struggling to dominate the person. At the end, sound and rational self wins, incorporated by the
patient.
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In hypnodrama, cognitive distortions may be destructed concretely. They can be stepped on,
buried, erased, scratched out. Worries may be blown into a balloon, and be released into the air.
Troubles may be blown away. Patients are asked that whenever anxiety dominates themselves
because compulsions are prevented, they would blow thier worries into a ballon in auto-hypnosis.
A 1995 meta-analysis by Kirsch et all showed a significant advantage when hypnosis is used
adjunctively in cognitive–behavioral therapy for a number of problems.
Although OCD, traditionally, is seen as a fear-based disorder, recent investigations report the role
of disgust in contamination-related OCD. Disgust was very important for humanity in preventing
contagious disease for thousands of years. OCD patients without washing compulsions did not
report feelings of disgust. Different emotion-based OCD cases are thought to be in different
categories. Access to affect is easier in hypnosis (in this way, spontaneous catharsis can be
possible). Manipulations against the central emotion can be done in hypnosis.
Hypnodramas directed to resolve the oedipal complex, to mitigate the urge of superego can be
used, to uncover the transference of the patient towards his/her therapist, and to provide
symbolism in the absence of dreams in psychodynamic therapy. They can also be used in
searching of the patient for a meaning, furnishing several opportune occasions in this search, and
provoking it in existential therapy.
Obsessive images and ideas may be a symbolic form of the patients’ unconcious thought crimes
such as frightening aggressive ideas. In this aspect, compulsions can be considered as one’s
atonement for his/her guilt in the form of rituals of cleansing (undoing). OCD is expected to
develop in persons that have the capacity to feel guilt. Using hypnodramas bearing the message
that hostile and selfish thoughts are understandable, to produce a cognitive belief may be helpful.
From a psychodynamical point of view, hypnosis is considered as a regression in the service of
the ego. Regression may be a key point in the psychodynamic therapy. Hypnosis is sometimes
used therapeutically to recover forgotten incidents, for example in cases of child sexual abuse.
Due to unreliability of hypnotic hypermnesia, and the risk of increased responsiveness to leading
questions and other sources of bias and distortion, such clinical practices should be performed
carefully.
Hypnosis can be used to promote relaxation, enhance imagery, and loosen the flow of free
associations
Behavioral, cognitive, dynamic, and existential elements that operate in the same patient should
not be considered as isolated factors (eclectic approach), but intermingled agents (integrative)
instead. They may interdigitate each other so as to form a single entity (wholistic approach)
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