I-CBT topics: How are obsessions created?

From an inference based CBT perspective, there is a reasoning process that occurs before someone experiences an obsession. We believe that people with OCD reason their way into an obsession. Here's how.

People with OCD have brains that reason in two different ways. The first type is normal reasoning. When someone is determining when it's safe to cross the street, if they want to give their dog one treat or two, if perhaps they’ve put on too much cologne, whether their morning coffee is too hot to drink, if they want guacamole on their burrito, or any other area where their OCD is not triggered, they are using normal reasoning. 

In normal reasoning, people with and without OCD use relevant associations, trust in the senses and self, and possibility, as well as direct evidence in the here and now to draw a conclusion. For example, if someone is using normal reasoning and they are deciding when it is safe to cross the street. They will probably look both ways, and see nothing, and they are trusting their sensory information. They're also using relevant associations, they associate the lack of cars with safe crossing, and while it's possible that there's a car coming, this possibility doesn't enter their awareness because their senses have told them it is safe to cross. They then cross the street.

However, when the OCD is triggered, someone with OCD will depend on obsessional reasoning, or inferential confusion. Unlike normal reasoning, obsessional reasoning uses irrelevant associations, distrust in the senses and self, and over-reliance on possibility, as well as a lack of direct evidence in the here and now to create an obsession. This reasoning leads to a confusion between reality and imagination. The obsessions and compulsions that are the byproduct of this type of reasoning create significant impairment in multiple realms of life. When someone relies on this type of reasoning and cannot tell imagination from reality, we say they are inferentially confused. For example, if someone with OCD is going to cross the street, they too may look both ways. And though they see no cars coming, they distrust that sensory information, they may also recall a story they heard of someone getting hit by a car they didn't see, and it's always possible that a car may zoom around the corner and hit them. They infer from this reasoning that it's not safe to cross the street, and will begin doing compulsions - that is, they use a real life behavior to solve an imaginary problem. They may avoid crossing altogether, ask someone they are with if it's safe to cross, outsource their trust to the people around them who are crossing, etc.

Of course, the alarm system of the brain is easily tricked by imagination. Consider a child running in to their parents' bedroom, complaining that there could be a monster under their bed or in the closet. The distress they experience is real, yet the threat is imagined. Obsessions will create real feelings and sensations of danger, disgust, and guilt, even though there is no perceivable threat in the here and now.

Obsessional reasoning has three distinct categories.

The first is Over-reliance on possibility. This is where people with OCD make a statement of possibility and rather than checking in with their senses or their common sense, they simply invest their attention in an imagined hypothetical. Possibility is around us all the time. It's possible that as I type this, the floor will collapse beneath me, or my dog is downstairs choking on a bone, or a car comes around the bend and slams into my house. It's raining, so it's possible my basement is flooding, or lightning will strike the tree outside of my window and a limb will fall on my house. All things are possible within the imagination, but without direct evidence that possibility is completely irrelevant.

• The oven might be on.

• It’s possible that I could harm someone.

• There might be dangerous germs on this surface.

• I might not be who I think I am.

• I could have hit someone with my car.

• It’s possible that I wrote something terrible in my work signature.

• I might trip and fall down the stairs.

• I could have a blasphemous thought.

The second is Irrelevant associations. These are pieces of information used to justify an obsession. These may come in the form of objective facts, rules from society, religion, family, or personal rules, things heard or read from sources other than the self, and things that have happened to us personally. Again, direct evidence is missing in obsessional reasoning, which is why these associations are ir-relevant. What has happened to someone else, somewhere else, or even to us in the past is completely irrelevant without direct evidence.

• One time, I locked my keys in the car by mistake.

• People can “snap”.

• Germs exist.

• One time, I was in such a bad mood that I told off my significant other.

• I’m not always paying attention when I drive.

• My friend accidentally sent a gossipy text to the wrong person.

• The stairs aren’t perfectly level.

• God is vengeful.

  
  

The third is Distrust in the sense and self. People with OCD trust their senses and selves in situations where the OCD is not triggered, yet distrust the senses and self in situations where the OCD is triggered. People with OCD do not have a problem with their perception, their perceptions are intact and the senses work as well in OCD situations as in non-OCD situations. For example, someone with OCD might be a highly competent, decisive surgeon who trusts themselves to carry out complex, life-threatening surgeries, yet doubt that they know their sexual orientation. The problem lies with the reasoning, and yet another way the OCD can trick sufferers is by causing them to selectively distrust their senses and themselves.

• I see that the oven light is off, but the oven might still be on

• I’m not angry or prone to violence, but I might still hurt someone

• I can see that the surface looks clean, but there might be germs

• Though I tend to be relatively stable, it’s possible I could snap

• I didn’t see anyone fly up and over the hood of the car, maybe I didn’t notice

• I’ve never written anything heinous in a work email, but I might have written something offensive this time

• I don’t see any dangers on the stairs, but falling is still a possibility

• I consider myself a faithful person, but God might still punish me

Together, along with a lack of direct evidence in the here and now, this obsessional reasoning process will cause someone with OCD to infer that there could be a problem when there actually isn't, and there never was. That is why we consider obsessional doubts to be inferences. Someone with OCD infers that there could be a problem, dismissing the available sensory evidence, using irrelevant associations (information out-of-context) and over-relying on possibility. It is this reasoning process that gives rise to obsessional doubts - what if the door is unlocked, I might hurt someone, I could be a different sexual orientation, etc. The obsession is the conclusion of the obsessional reasoning process. You can think of it like this:

Irrelevant Associations + Over-reliance on possibility + Distrust in Senses/Self - Direct Evidence = Obsessional Reasoning

For example, the reasoning "I've forgotten to lock the doors before, and robbers can get in, I heard that there was a serial killer who would take unlocked doors as an invitation to enter" concludes in the inference of doubt: therefore, my door might be unlocked right now. It is this reasoning process that creates an obsession, and it's for this reason that the inference of doubt is the treatment target in I-CBT.

Adapted by Katie Marrotte from: O’Connor, K., & Aardema, F. (2012). Clinician’s handbook for obsessive compulsive disorder: Inference-based therapy. Chichester: Wiley-Blackwell. www.icbt.online