Do people act on their intrusive thoughts? If no, has this been proven? And are compulsions the opposite of impulses in terms of people acting or not acting on their thoughts?

First, my thoughts on whether compulsions are the opposite of impulses are that in OCD a compulsion is to “prevent” harm; yet, an impulse outside of OCD can potentially cause harm. For example, when an OCD thought occurs and a person feels they are urged to act on that intrusive thought (e.g., harming oneself or someone else) it can seem a bit like Russian roulette. However, when a person who has an impulse control disorder is faced with an impulse to harm oneself or someone else this is like Russian roulette.

How do you mean?

Well, Russian roulette is a game of high risk in which each player in turn, using a revolver containing one bullet, spins the cylinder of the revolver, points the muzzle at the head, and pulls the trigger. The question is which player will get the bullet?

In likening the risk with OCD, let’s say OCD says to Mr Johnson (who has suicidal intrusive thoughts and is trying to sleep), “Take the gun from your drawer and shoot yourself.” This leaves Mr Johnson in a “fight” or “flight” situation. Will he be the player who gets the bullet – that is, by fleeing the situation to bring his anxiety down momentarily and to “prevent” a bloody scene? Or will OCD be the player who gets the bullet?

Where is this leading, and how would OCD get the bullet? 

What would happen is that should Mr Johnson continue trying to sleep instead of escaping the obsessional scene then OCD would get the bullet. But because OCD is an anxiety disorder, Mr Johnson unfortunately becomes so panicked that the urge to escape the “dangerous” situation overwhelms him. He then follows through immediately with the escape plan, and OCD wins the “game”, so sadly Mr Johnson gets the bullet.

The compulsion (fleeing) is a negative response which strengthens Mr Johnson’s fear-related obsession, and so OCD continues to win. Other compulsive behaviours occur too, such as checking, praying, avoidance, or seeking reassurance that no harm has, is or will occur which puts Mr Johnson in a bad predicament.

Now despite the fact that OCD thoughts are paradoxical to Mr Johnson’s true wishes and desires (it’s his obsession that tells him he is suicidal, not him) this unfortunately is of little use to him. Much of this is due to doubts and “what-ifs?” plus erroneous beliefs seen in OCD; thus, he continues to yield to compulsions “just in case”. What he doesn’t trust yet is that obsessions do not convert to action meaning no compulsions are required to keep him from danger.

But is there any proof that he won’t carry out his obsession?

One theory of proof that obsessions do not convert to action is for Mr Johnson to consider how the perception of body movements (kinaesthesia) work. This involves being able to detect changes in body position and movements without relying on information from the five senses. Even though this confirms that any obsessional urge will be automatically restricted it’s more important to note that obsessions are invalid pieces of information firing into the consciousness, signifying that these are non-existent thoughts and will never materialise into any form of action anyway.

But if the urges are so strong, how do these differ from impulsive urges outside of OCD?

As far as impulses go, and when these are OCD-related, the urge can feel very strong. This is why they yield to the corresponding compulsive responses to “prevent” perceived harm, just like Mr Johnson does. Still, when referring back to kinaesthesia coupled with contradictory information coming into the mind, proves again that compulsive responses are not required.

How does kinaesthesia differ from obsessional urges seen in OCD and those seen in impulse control disorder (ICD)?

An impulse seen in an ICD is a challenging and dangerous action; yet, an impulsive urge seen in OCD is an obsessional fear that a dangerous action could occur, hence the repeated compulsions to ward off perceived danger. As the term shows, ICDs are a class of psychiatric disorders characterised by impulsivity, not obsessions. For example, one person with an ICD had an ongoing impulse to run across roads and reach the pavement before oncoming cars reached her. In contrast another person had an obsession to do a similar thing yet avoided going near roads, which clarifies the difference between harmful impulses seen in an ICD and avoidance of harming obsessions seen in OCD. The same goes for someone suffering from kleptomania, the impulse to steal differs for the person who has an obsession to steal. Further, someone who cannot resist the impulse to expose himself in public differs from another person who has an obsessional urge to expose himself, and so on.

So ultimately, what can Mr Johnson do to make sure OCD gets the bullet instead of him?

By resisting compulsions in graduated steps Mr Johnson will begin starving the obsession and OCD will eventually get the final bullet. O.C.D. – An Effective Strategy for Resisting Compulsions

Summary

It can be determined that impulsive urges within the obsessive-compulsive category are not acted upon; yet compulsions to ward off perceived danger and to relieve anxiety are acted upon, but are not required. In addition, there appears to be no problems in the process that describes kinaesthesia in the way there is in those who have an ICD. While no theory need be explained why obsessions cannot possibly come about it does provide an avenue of thought for those who desire some level of proof. In sum, an obsession is just that which means intrusive thoughts never come true. Impulses in the ICD group on the other hand can occur and kinaesthesia impairment is likely one of the causes.

© Carol Edwards 2017

Impulse Control Disorders: Updated Review of Clinical Characteristics and Pharmacological Management

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