What are compulsions
From an etymological point of view, the term compulsion , referring to human behavior, derives from the Latin verb compell ĕ re which means “to push hard ”. Today the adjective compulsive , according to the literal meaning, is equivalent to the term “constricting” or “uncontrollable”.
It is precisely this literal meaning of the adjective that is often used, in common language but also in the psychological technical one, to indicate the tendency to carry out behaviors in a poorly regulated or forced way.
The same Treccani vocabulary says: compulsive adj. [der. of compulsion ]. – In psychiatry, of impulse, behavior, act and the like, which is performed by a subject in a mechanical and unstoppable way, as a symptom of a variety of behavioral and neurological disorders.
In fact, the term compulsion , in psychology and psychiatry, is often associated with all the problems of addiction and impulse control . In these psychopathological pictures, the subject is unable to resist an impulse and yields to the compelling temptation to engage in dangerous or dysfunctional behaviors. The act is usually preceded by a growing feeling of arousal followed by gratification and / or relief.
Let’s take the example of compulsive shopping . In this disorder the subject, starting from mental states characterized by unpleasant emotions (boredom, sadness, emptiness, etc.), is seized by the irrepressible sense of urgency with respect to buying (compulsions). The actual act of compulsive buyingit is accompanied instead by emotions of temporary excitement, pleasure and gratification. For a behavioral mechanism of positive reinforcement (given by gratification) and negative (reduction of previous unpleasant feelings) the behavior is nourished and the problem self-maintains itself over time, generating even serious harmful effects on personal functioning (economic and social problems, for example ) but also profound subjective suffering (eg, feelings of guilt and shame with themes of contemptuous self-criticism).
In the case of compulsive shopping , the compulsion to buy turns out to be both an impulsive act (the person cannot resist the temptation) but also compulsive (repeated and perceived as uncontrollable). This also applies to other substance use disorders or impulse control disorders.
Compulsions in Obsessive Compulsive Disorder
In the field of psychopathology, the term compulsion is also central to the phenomenology of Obsessive Compulsive Disorder ( OCD ) . OCD is in fact characterized by the intrusive and recurring presence of thoughts, doubts, impulses and mental images ( obsessions ) that generate intense discomfort, which is then reduced or temporarily eliminated by the subject, through actions with reassuring value ( compulsions ).
By definition, compulsions in OCD are: “Repetitive behaviors (eg, washing hands, tidying up, controlling) or mental actions (eg, praying, counting, repeating words mentally) that the subject feels compelled to put into act in response to an obsession or according to rules that must be strictly applied. Behaviors or mental actions are aimed at preventing or reducing anxiety or discomfort or at preventing some feared events or situations; however, these behaviors or mental actions are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive ”(from DSM-5; APA, 2013).
Too often, OCD compulsions are confused with other afinalistic and finalistic behaviors within disorders of various kinds. Just think of certain behavioral symptoms within neurological syndromes or pervasive developmental disorders: in these cases, stereotyped motor mannerisms, tics or ritualized actions are all behaviors without an underlying motivational purpose that instead characterizes compulsions .
If that weren’t enough, there are purposeful, ritualized, and forced behaviors related to other disorders that have underlying purposes very different from OCD compulsions . We think, for example, of the repeated checks that patients with eating disorders carry out with respect to weight and body shape or the checks aimed at the behavior of others of paranoid subjects or with persecutory delusions. There are also behaviors of continuous search for closeness in separation anxiety disorders and the already described pleasure-seeking behaviors typical of pathological addictions .
In OCD , the compulsion instead fulfills a very specific purpose which is that of reducing the discomfort associated with feared mental events (obsessions). In particular, thanks to research in the cognitive-behavioral field, we have come to understand that the underlying purpose of compulsions can be placed within 3 major motivational areas:
- Avoiding feared harm to oneself or to others (what the British colleagues call harm avoidance): this category includes all the compulsions aimed at reducing anxiety or fear related to the possibility that, due to one’s inattention or lightness, terrible events can occur, such as, for example, contagions of diseases, accidents, economic damage, unfortunate events of a superstitious nature.
- Avoid or reduce emotions disgust ( disgust avoidance): fall into this category acts to reduce or cancel the discomfort associated to the alleged contamination with waste substances (eg., Feces, urine, semen, saliva, hair) or with organic residues of people considered disgusting by the subject (eg, homeless people, drug addicts, prostitutes, people considered morally deplorable).
- Avoid or reduce feelings of “not being right” ( not just right experience avoidance): this category includes all compulsive actions that reduce or eliminate the subjective feeling that everything is not completely “right” and that something in oneself or in the surrounding world is not “as it should be”.
From what has just been said, we understand how the same compulsive behavior can have completely different underlying reasons. Let’s think, for example, of compulsionsof reordering and symmetry. Only by asking ourselves – and asking the patient! – what is the underlying fear, we can understand if the purpose is to cancel a superstitious fear (“Doctor, if my documents are not perfectly stacked one on top of the other, a misfortune could happen to my loved ones”) or rather to contain a fear of being lost (“Just by keeping my documents aligned I am absolutely sure they are all in place. If I lost them it would be a disaster and I would be fired for sure!”) or, finally, to avoid the unpleasant feeling of not being right ( “I feel uncomfortable if the documents are not all arranged that way. I just can’t stand it and I can’t do anything if I don’t feel” right “!)
On the other hand, the same obsessive fear can be canceled or reduced through different compulsive strategies : a hypothetical patient with OCD , for example, could pursue the aim of reducing the fear of contagion both with compulsive washing rituals and with repeated checks that their clothes do not have hypothetical stains attributable to infected blood.
In conclusion, too often in psychiatry and psychology, we are faced with diagnostic frameworks based purely on symptoms, especially behavioral. This could lead us to leave out a question that is fundamental in our profession. What function does that behavior have?
In fact, from what has been said, the need to understand the specific motivation underlying the compulsion derives in order not only to correctly frame the person’s problem, but also to lay out individualized psychotherapeutic interventions based on the meanings underlying the behavioral symptom.
