Treating OCD with pathological doubt with the systemic approach

Obsessive compulsive disorder (OCD) affects millions of people today. The treatment, to be effective, requires first defining the type of OCD from which the patient suffers. This article details the treatments adapted to OCD with pathological doubt, the triggering factors, the symptoms and the treatments using the systemic approach.

An interactional reading involves a more personalized understanding of OCD, recognizing that individuals may experience and manifest their symptoms in unique ways. This approach promotes personalization of treatment, with a more in-depth exploration of underlying dynamics which helps to improve therapeutic engagement. While the DSM provides a structured framework for classifying disorders, interactional reading enriches clinical understanding by highlighting the diversity of OCD experiences and informing therapeutic approaches tailored to each individual.

Determining the nature of OCD

The treatment will be oriented according to the nature of the OCD observed: OCD with rituals , OCD without rituals or pathological doubt , pathological doubt .

OCD with pathological doubt, what is it?

In the study of obsessive-compulsive disorders , it is frequently observed that individuals may experience deep anxiety about committing, or having committed, acts perceived as wrong, shameful, harmful, or dangerous to themselves. or for others. This preoccupation often leads to attempts at excessive control, manifested by the avoidance of precautionary actions or the constant search for reassurance. The fear of losing control and succumbing to unwanted impulses is a characteristic aspect of this disorder, highlighting a typically obsessive-compulsive perception-reaction system.

Doubt , often centered around guilt- or fear-inducing topics, is a powerful driver of this behavior. Whether related to moral judgments, the past, or even attention span, these concerns lead to precautionary measures and requests for reassurance, thereby transforming doubt into an obsessive-compulsive cycle. The individual seeks rational answers to these irrational doubts, often by asking questions, consulting external sources such as the internet, or asking other people.

How to recognize pathological doubt

Strategic questions are essential to assess and understand the nature and impact of patients' obsessive thoughts and behaviors. They help guide therapeutic interventions by targeting specific aspects of the disorder and adapting intervention strategies. Here is a detailed exploration of policy questions relevant to obsessive-compulsive disorder focused on pathological doubt:

Question the prevalence of thoughts:

Is there a predominance of certain thoughts or are doubts more frequent?
This question aims to assess the balance between the individual's beliefs and uncertainties, making it possible to identify the weight of obsessive thoughts.

Understanding the evolving nature of thoughts:

Have the thoughts or doubts always been the same type or have they changed over time?
Understanding the course of obsessive thoughts can help identify specific motives or triggers, as well as the progression of the disorder.

Question the focus of thoughts:

Are the thoughts primarily about the individual himself or do they also involve others?
This question helps determine the extent and focus of obsessive concerns, which is crucial for targeting interventions.

Question the satisfaction of the answers:

Are the answers that the individual finds to his questions or doubts satisfactory or do they lead to the emergence of new thoughts or doubts?

Identifying whether responses provide temporary relief or further fuel the obsessive cycle is essential for planning effective interventions.

Understanding TSR to process thoughts:

How does the individual manage his thoughts and doubts: through concrete actions or through reflection?
Understanding whether the individual is more inclined to act or reflect can influence the type of treatment prescription offered.

Question distraction strategies:

Does the individual actively try not to think about their concerns or engage in deep thought about them?
This question helps discern the defense mechanisms and avoidance strategies employed by the individual.

Question the effectiveness of actions:

Does what the individual does to manage their doubts help them understand and overcome their problems, or does it generate new doubts and thoughts?
Evaluating the effectiveness of the individual's current strategies helps determine whether these strategies need to be strengthened or modified.

Questioning external dependence:

Are the answers the individual finds sufficient on their own, or do they feel the need to seek validation and reassurance from other people?
Understanding the level of dependence on external sources of reassurance is crucial to encouraging greater autonomy in managing doubts.

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Treatment of OCD with pathological doubt: prescriptions

One of the key maneuvers for those suffering from pathological doubt is to dismiss doubt by avoiding answering intrusive questions, drawing on Kant's maxim that there is no intelligent answer to questions. stupid. Alternatively, writing down the questions and answers can lead to saturation and a conscious takeover of doubts. These techniques rely on the illusion of alternatives, placing the individual in a situation where, regardless of the option chosen, they progress towards greater cognitive autonomy.

In cases of paralysis due to doubt, one approach may be to flip a coin, providing a decision-making alternative. Even in this process, the individual is required to make an active decision, moving from passivity to action. The goal is to break the cycle of obsession and catalyze the transition from sterile reflection to constructive action.

Prescriptions in the treatment of obsessive-compulsive disorder focused on pathological doubt and fear of wrongdoing aim to disrupt the cycles of thought and behavior that fuel anxiety and obsession. These interventions are designed to help the individual regain control of their thoughts and reduce reliance on rituals of verification and reassurance. Here is a detailed description of the prescriptions commonly used in this context:

- Response inhibition : This technique consists of encouraging the individual to actively resist the urge to answer intrusive questions or doubts. By avoiding providing answers, the patient gradually learns to tolerate uncertainty and reduce the frequency and intensity of obsessive thoughts. The goal is to break the cycle of seeking reassurance that fuels the disorder.

- Saturation of thought : The individual is invited to write down all the questions and answers that come to mind concerning their obsessive doubts. This task, often tedious, aims to get the patient to recognize the absurdity or repetitiveness of their thoughts. By visually confronting the clutter of one's doubts and the uselessness of one's responses, the individual can achieve a sort of "cognitive saturation" which reduces the power of obsessive thoughts.

- Avoid answering intrusive questions : Inspired by Kant's philosophy, patients are sometimes advised to adopt the attitude that there is no intelligent answer to stupid questions. This approach aims to encourage individuals to recognize the irrationality of some of their concerns and to consciously choose not to commit cognitive resources to the search for answers.

-Write to achieve saturation : Similar to thought saturation, this prescription requires the individual to write down exhaustively all of their concerns and the responses they are considering. This process can reveal the cyclical and redundant nature of obsessive doubts, leading the individual to experience cognitive fatigue that discourages further rumination.

- The illusion of alternative : This technique offers the patient two choices, each leading to a strengthening of their autonomy. For example, in a situation where an individual is paralyzed by doubt, ask them to make a decision through a coin toss. If, while the coin is in the air, the individual manages to make a decision, they can ignore the outcome and choose what they really want to do. This method encourages the individual to recognize and act on personal preferences, thereby reinforcing the sense of control and agency.

By combining these prescriptions with a therapeutic approach adapted to the specific needs of each individual, the goal is to establish lasting changes in the management of obsessive thoughts and behaviors. The emphasis is on reducing reliance on rituals of checking and reassurance, as well as improving the ability to tolerate uncertainty and anxiety without resorting to compulsive behaviors.

In therapeutic communication , metaphors and aphorisms such as Hamlet's dilemma, "to be or not to be", Kant's reflection on stupid questions, and the idea of demolishing the scaffolding of doubts are used to facilitate a reconceptualization of the patient's problems. These rhetorical tools help destabilize obsessive thought patterns and encourage a more flexible and nuanced approach to managing uncertainties and fears.

The systemic and strategic approach is very effective in the treatment of OCD. Obsessive and compulsive disorders are part of the psychopathologies studied in the third year of the LACT course and in the Clinical Master of Giorgio Nardone (CTS) .

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