1. Teori dan dasar empiris

Pengaruh antara obsessive–compulsive disorder (OCD) dengan pengalaman traumatik telah

diteliti secara terus menerus pada komunitas dengan gangguan cemas. Beberapa peneliti

mengacu pada Janet’s work pada 1903, ditemukan bahwa trauma dapat mempengaruhi

perkembangan penyakit psikiatri (de Silva & Marks, 2001). Sayangnya, pengetahuan ini

sedikit mempengaruhi perkembangan terapi yang tersedia untuk pasien dengan OCD yang

disebabkan oleh pengalaman traumatik.

1.1. Prevalensi

Menurut Diagnostic and Statistical Manual of Mental Disorders, edisi ke lima (DSM-V;

American Psychiatric Association [APA], 2013), 1.1–1.8% populasi dunia mengalami 12

bulan kejadian OCD. Wanita mengalami lebih tinggi angka kejadian OCD pada saat dewasa,

sedangkan laki-laki lebih tinggi kejadian OCD pada masa anak-anak. Rata –rata kejadian

post-traumatic stress disorder (PTSD) kira-kira 3.5% (APA, 2013). Hal ini tidak termasuk

individu yang mengalami distress yang berhubungan dengan trauma tapi tidak sesuai dengan

kriteria PTSD yang didefinisikan oleh DSM-V. Menurut Gershuny and Thayer (1999),

beberapa orang mengalami beberapa kejadian traumatik yang menyebabkan distress

psikologis. Kejadian OCD selama 12 bulan, 30 % merupakan orang dengan PTSD, yang

secara signifikan lebih tinggi dalam populasi umum (Badour, Bown, Adams, Bunaciu, &

Feldner, 2012). Kejadian OCD setelah insiden traumatik (tidak menyebabkan PTSD) telah

diteliti dengan hasil yang bervariasi rata-rata dari 30% sampai 82% tergantung pada populasi,

dimensi dan standar (Cromer, Schmidt, & Murphy, 2006; Fontenelle et al., 2012; Gershuny

et al., 2008). Meskipun bukti prevalensi spesifik mengenai rata-rata trauma yang

menyebabkan OCD tidak meyakinkan, informasi mengusulkan bahwa harus dipahami secara

konseptual untuk meangani pasien OCD dengan pengalaman traumatik.

1.2. Memahami obsessive–compulsive disorder (OCD) dan trauma-related distress

OCD adalah kelainan neuropsikologis yang dicirikan obsesi dan kompulsi yang tidak dapat

dikontrol yang menyebabkan distress yang bermakna pada individu (APA, 2013). Obsesi

merupakan pikiran, keinginan, atau bayangan yang tidak menyenangkan dan terus menerus

terjadi pada individu. Obsesi menyebabkan ketidaknyamanan pada individu dengan OCD

melalui timbulnya cemas dan perasaan bersalah tergantung dari jenis obsesi (APA, 2013).

Individu penderita OCD akan mencoba menolak, mengatasi, atau menetralisir obsesi dengan

perlakuan penyangkalan atau kompulsi (APA, 2013). Obsesi mungkin sangat tidak logis,

berlawanan dengan intuisi, dan tidak berhubungan dan obsesi ditemukan pada beberapa

populasi. Miklowitz, and Craighead (2013) merangkum pokok obsesi menjadi beberapa

kategori yaitu : (a) pencemaran; (b) perasaan bersalah dan tanggung jawab terhadap bahaya

kekerasan, dan fitnah; dan (e) kebutuhan terhadap urutan dan simetris. Individu dengan OCD,

kompulsi yang mengikuti pikiran, bayangan, keinginan obsesi memiliki peran spesifik untuk

mengurangi ketidaknyamanan pasien tapi tidak memiliki hubungan logis dengan obses (APA,

2013). Contoh, jika pasien dengan OCD mengalami obsesi seperti “keluarga saya dan teman

akan terluka” maka pasien tersebut akan menetralisir obsesinya dengan melakukan kompulsi

yaitu dengan menyalakan dan mematikan lampu delapan kali sebelum keluar rumah.

Sebagian besar pasien menyadari obsesi dan kompulsi tidak beralasan; meskipun begitu

beberapa pasien (kira-kira 4 %) yang memiliki insight negatif/delusi kepercayaan mengenai

obsesi kompulsi mereka (APA, 2013, p. 237).

Trauma yang berhubungan dengan distress didefinisikan sebagai distress psikologis yang

merupakan akibat dari kejadian yang membuat stress (APA, 2013). Distress psikologi

memiliki manifestasi khusus yaitu pikiran yang mengganggu ( contoh : sorot balik, mimpi

buruk, siaga berlebihan) yang secara khusus mengenai kejadian traumatik yang dialami.

Gejala yang dialami individu mungkin bervariasi dan tergantung situasi. Kadang gejala yang

timbul adalah kecemasan atau perasaan takut. Di waktu yang lain gejala yang timbul adalah

gejala depresi, kemarahan dan penyerangan atau pemisahan diri. Kombinasi dari gejala

tersebut muncul setelah kejadian yang menyebabkan distress terjadi (APA, 2013). Beberapa

teori mengenai OCD telah dikemukakan sejak dahulu. Penulis akan meneliti PTSD untuk

memahami jenis distress yang disebabkan oleh trauma.

1.2.1. Cognitive-behavioural models of OCDPsychological models suggest that OCD develops out of a unique relationship between an individual’spsychological functioning and his/her environment. Cognitive-behavioural models arethe most widely accepted theories in explaining and understanding OCD (Craighead et al.,2013). Beck theorized in 1976 that dysfunctional adaptation is not a result of specific events,but rather an individual’s inability to process and make sense of a said event (as cited in Craigheadet al., 2013). Intrusive thoughts are experienced by roughly 80–90% of the general population(Briggs & Price, 2009). Despite the common occurrence of intrusive thoughts, the majority ofpeople do not develop OCD. Normal intrusive thoughts transition into clinical obsessionswhen the individual takes on personal significance or responsibility for the thought. Forexample, an individual on vacation may experience the intrusive thought that someone is breakinginto his/her home while he/she is away. The majority of the population would dismiss this thought

as being insignificant and would relatively quickly assume that he/she has locked the door and allis well. A small portion of the population, however, would not be able to dismiss this thought andit may turn into a clinical obsession. The individual would then take on personal responsibility forevents related to the thought (i.e. “if I think about it, it is sure to happen” or “I must take extraprecaution to ensure it does not happen”). These thoughts would then become so intrusive thatthe individual would need to complete some action (i.e. refusing to go on holidays, replacingthe negative thought with a positive thought, or checking that the door is locked a certainnumber of times before leaving) in order to reduce the distress he/she is feeling (Craigheadet al., 2013).Salkovskis, in 1985, was one of the first to develop a comprehensive cognitive-behaviouralunderstanding of OCD. Previously, the most widely accepted theory was a behavioural model,which ignored the obvious link between cognition and psychopathology. Salkovskis (1985) combinedthe largely accepted behavioural theory with the relatively new cognitive theory. Hebelieved that by combining behavioural and cognitive theories and treatments, clinicianswould be able to use new approaches to intervene on treatment-resistant OCD. According toSalkovskis (1985), each person encounters potentially triggering stimuli at many points throughoutany given day. Individuals who struggle with obsessional thinking, however, will activelyavoid encountering potentially triggering stimuli. Salkovskis (1985) defines these intrusivethoughts as inherently ego dystonic (“the content is inconsistent with the individual’s belief system, and is perceived as objectively irrational”, p. 578), and thus, the individual’s reaction isdetermined by how impacting the intrusive thought is for the individual person. When the intrusivethought is viewed as being important and the individual places meaning on it, the person’sbelief system is shifted. The person takes on ownership, responsibility, or blame for the intrusivethoughts, which become automatic thoughts that are ego syntonic and result in affective disturbances(Salkovskis, 1985).In Salkovskis’ (1985) model, next the individual may engage in neutralizing behaviour inorder to reduce distress, which, if successful, reinforces the neutralizing behaviour. Even if theneutralizing behaviour does not reduce the anxiety, the unwanted event may not happen. Formany, this is also a strong reinforcer and may also encourage more neutralizing behaviour inthe future. If neither of the previous scenarios takes place, the neutralizing behaviour maybecome a powerful and unavoidable trigger in and of itself. Admittedly, Salkovskis (1985) identifieda few challenges associated with his cognitive-behavioural model of OCD. Nevertheless, histheory created the groundwork for more advancement of the cognitive-behavioural understandingof OCD.In 1997, Rachman proposed a cognitive theory of obsessions, which was developed out of the

aforementioned cognitive theory of OCD from Salkovskis (1985). In this theory, Rachman (1997)suggests, “obsessions are caused by catastrophic misinterpretations of the significance of one’s intrusive thoughts” (p. 793). As noted previously, most people experience intrusive thoughts,but Rachman (1997) identifies some differences between typically intrusive thoughts and atypicalobsessional thoughts. Obsessions last longer, are more intense, more persistent, cause more distress,and create more lasting impact on the individual (Rachman, 1997, p. 793) and yet thecontent of typical and atypical intrusive thoughts are quite similar. Additionally, Rachman(1997) identified the key element that differentiates typical obsessions with problematic obsessions;namely, meaning. The meaning that an individual places on an intrusive thought,whether it be interpreting these thoughts as being “very important, personally significant, revealing,threatening, or catastrophic” (Rachman, 1997, p. 794), can shift a universally experiencedand dismissed thought to an unavoidable obsession.Rachman’s (1997) theory also suggests obsessions are more likely to occur when an individualis exposed to stressful situations and that external cues often trigger obsessionalthoughts. The more stressful the external cues, the greater the frequency of intrusive/obsessionalthoughts, the greater the distress the individual will likely feel (Rachman, 2002). These stressfulsituations may be traumatic and/or aversive, which may provide evidence for the link betweentrauma and OCD. In 2002, Rachman suggested a similar theory for compulsions (specifically,compulsive checking). He suggested that compulsions occur when an individual believes he/shehas a special responsibility to prevent unwanted events from occurring. Again, this theory canbe applied to an understanding of trauma-related distress. If an individual feels responsible toprevent the traumatic event from reoccurring, he/she may respond with compulsions (as inOCD) or hypervigilance (in PTSD) or some other attempt to neutralize the anxiety experienced(Rachman, 1998).1.2.2. Cognitive-behavioural models of PTSDTraumatic events result in primarily psychological symptoms; namely, “repeated and unwantedre-experiencing of the event, hyperarousal, emotional numbing, and avoidance of stimuli (includingthoughts) which could serve as reminders for the event” (Ehlers & Clark, 2000, p. 319). Aswith OCD, many people experience at least some of these symptoms at some point in their lives.Most people’s symptoms dissipate after a few months and no longer cause distress. There is a subgroupof the population, however, who experience these symptoms for many years after the event.520 K.L. DykshoornDownloaded by