OCD

Having done some blog posts in the past on the sources of anxiety, I wanted to do a bit of a deep dive into a specific kind of anxiety that I see quite a bit in my clinical work. Obsessive Compulsive Disorder. Now I know that many of us have seen this one portrayed in the movies. We think “ah yes, washing your hands too much” or “germaphobes” and while it’s true that sometimes OCD looks like that, I wanted to talk some more about it because many times it looks very different. Many times, when I’m working with someone and make a diagnosis of OCD they are very surprised and relived to find out that their symptoms fit under that umbrella as well. It’s not uncommon for me to get clients that have had this form of anxiety diagnosed as just about everything else under the sun: specific phobia, social anxiety disorder, PTSD. Having the right name for what’s going on sometimes is half the battle. 

So, what the heck is OCD? Well, according to the DSM-V-TR (the counseling field’s big blue bible of diagnoses). OCD is characterized by obsessions and compulsions that take up more than 1 hour per day and cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning. To use the well recognized handwashing caricature as an example; the fear that one’s hands might be dirty, the preoccupation with trying to convince oneself that they didn’t get contaminated by touching X, Y or Z —that would be one example of an obsession. The washing and re-washing of the hands would be the compulsion. In general the obsession generates a lot of fear and anxiety and the compulsion is an effort to neutralize it in someway. 

Let’s unpack what an obsession looks like in greater detail. Obsessions are often triggered by something called an “intrusive thought.” An intrusive thought is exactly what it sounds like. All of a sudden, out of nowhere, a thought pops into your mind. The harder you try not to think the thought, the stickier it becomes. A practical example of this is if I were to tell you right now: “Don’t think about purple elephants.” Even for a non-OCD brain, it’s hard not to hear “purple elephant” without conjuring up images and thoughts of purple elephants in your mind. The harder you try not to: “Don’t think about it, don’t think about it, don’t think about it” the more you are dooming yourself to think of nothing else. With our hand washing example, a pretty typical intrusive thought goes something like “maybe that thing I just touched was contaminated with a horrible disease” The intrusive thought typically jump starts the obsession which might turn into a mental inventory of all the things you’ve touched recently, unsuccessful rationalizations of why it’s not likely that you are contaminated with a horrible disease, catastrophic thoughts about who you could transmit a hypothetical horrible disease to aaaaand eventually this leads to a compulsion.

A compulsion in this case, would typically look like a thorough scrubbing of the hands, followed by even more scrubbing of the hands annnd because you’re now having intrusive thoughts that maybe you missed a spot there will be yet more washing of the hands. Many people with this specific type of OCD will often have chapped and bleeding hands because they just can’t shake the fear that they are contaminated in some way shape or form. As I mentioned earlier, compulsions are almost always a way of neutralizing scary and anxiety producing thoughts and obsessions. They can be covert and hard to see: rationalizing, trying to remember exactly what you did, prayer ect. They can be overt and easy to see: hand washing, cleaning, repeated checking, setting extra guardrails against a feared act, seeking reassurance from others about our doubts. The reason why obsessions are followed by compulsions is that a compulsion does provide partial and temporary relief. This in turn creates a classic reward cycle that is reinforced over and over again by repetition, etching it deeper into your gray matter as a nearly automatic response to the stimuli of an obsession. 

We could go down a rabbit trail here to revisit old Pavlov and his dog. Ivan Pavlov, as you might remember was a soviet guy that became one of the fathers of behavioral psychology. He ran this famous experiment whereby every time he fed his dog, he would ring a little bell. Eventually, every time the dog heard the bell, it would start salivating whether there was food coming or not. OCD works in a similar way, but instead of operating off of our appetite drive, it operates off of our fear drive. We experience anxiety and or obsessions (after a while, either one will trigger the other in this disorder), and because both these things are unpleasant we cast about for a way to get rid of them and preform a compulsion. Once you’ve completed the compulsion, once you’ve compulted (that’s my new word), you experience some temporarily relief. Your brain notices this and links the two together - the compulsion as the answer to the unpleasant thought or feeling. And once you’ve completed that cycle enough times you start to loose control - your mind starts to insist more forcefully that you do that Same. Damn. Response. Every. Single. Time.

Now, that we’ve got the basics down using a well-recognized form, let’s talk about why the hand-washing type of OCD is a little too 2-dimensional to capture most experiences of the disorder. The reason why so many people with OCD go undiagnosed for such a long time is that intrusive thoughts can be very embarrassing and disturbing to the person with OCD that experiences it. People don’t really want to admit to their intrusive thoughts because they worry that it’s something that only happens to them. Intrusive thoughts can take a lot of different forms and some of them can be fairly dark and disturbing. The kicker though is that everyone, OCD and non-OCD alike will have dark intrusive thoughts float through their mind multiple times per day. You might have a stray thought about rape, or child molestation, or jumping off of a building, shoplifting, lying to someone, driving into traffic. If you’re religious, you might have worries that you’ve sinned in an especially unforgivable way. You might have a thought that maybe you hit someone in your car a few turns back and didn’t even notice. You might have thoughts that there is something wrong or incorrect about your body. You might even have a superstitious thought such as: unless I preform X, Y or Z ritual, someone might get hurt. Most people shake it off as a random phenomenon and don’t even take notice. People with OCD do notice and become very anxious about what such a thought might mean. “Does it mean that I might do it?” (By the way, there does not seem to be any correlation between having these thoughts and engaging in these behaviors. It’s a bit of a paradox actually that an OCD mind is probably the least likely to follow through with a dark thought and yet the most scared of what a dark thought might actually mean). Actually, my experience as a clinician is that the more you are disturbed by an intrusive thought as an OCD person, the more likely you are going to fixate on it. The stronger the danger signal it flares in your amygdala (the part of your brain that generates fear), the more insistent your mind will be that you find a way to neutralize it. 

And now I feel like I probably owe the reader that has made it to this point of the blog some information about what can be done if your brain has fallen into these patterns. In the old days OCD didn’t typically have a great prognosis; meaning that if you had the symptoms described above, you would usually keep having those symptoms. The first break through with OCD treatment came with the development of something called “Exposure Response Prevention” or ERP. In essence, in this early model of treatment, you would be exposed to triggers of your obsessive fears, and prevented from doing any of your compulsions. By doing this over and over again you would eventually reach “habituation” of your fear response. In other words, your body and mind would learn eventually that they can experience an obsessive fear in the absence of a compulsion and still survive with none of the feared outcomes. As this learning unfolds, the anxiety response diminishes and the frequency and duration of obsessions also diminishes. The downside of this type of therapy is that it was really uncomfortable and tended to have very high drop-out rates. This sort of makes sense: imagine that you’re terrified of spiders, and your treatment consists in letting one crawl on you. Even though it appears very efficacious to do this, it’s understandably a hard sell for some people. (Incidentally, this treatment protocol has also been used for phobias and PTSD at times). The next break through for OCD treatment was a pharmaceutical one. Medications, (usually in a class called SSRIs) can be wonderful at decreasing symptom intensity and can be a life changer. They tend to be more of a palliative then a cure though, meaning that once you stop taking them, your symptoms are likely to come back. The newest breakthrough in OCD treatment, and the one that I use with clients is called “acceptance and commitment therapy.” This approach still utilizes exposure and response prevention, but it incorporates more skill building to develop tools to help with the experience of uncomfortable emotions. It also puts people into contact with important values that they want to live their life by that can help with motivating them to push through their discomfort.

As a therapist, for almost every other client concern, I don’t like using workbooks and giving homework. With OCD though, it’s completely different. I find it very useful to have my client’s work through Marissa Mazza’s “The ACT workbook for OCD” doing about a chapter a week while working with me on a weekly basis as well. I don’t work with kids anymore, but when I did have child clients with OCD, I liked the workbook “What to do when your brain gets stuck” by Huebner and Matthews.  I don’t recommend “going it alone” with the workbook because OCD is a bit of a shape-shifter. The moment you start to build progress against one type of obsession, your OCD typically starts to manifest in new ways that are unfamiliar and hard to recognize. Working with an experienced therapist is important at this stage, otherwise you’ll likely just swap fixations and feel more stuck. 

Living with OCD is intense. Overtime it is not uncommon for the anguish from OCD to precipitate depressive episodes. Also, because obsessions and compulsions take so much time to complete, it’s pretty normal for people to start seeing secondary impacts  on their functioning in important realms (like work or relationships). A metaphor many clients use to describe their experience is that of a cage - they feel stuck and trapped and don’t know how to exit the narrow confines of their mind. I love working with people that have been stuck in the cage for years when they start to realize that they can live beyond the confines of their obsessions. Many people with OCD are incredibly sharp and productive people once they get to the other side of the disorder. It’s a feeling similar to that of wearing a heavy backpack on a long trip. When you finally get to take it off, you feel so much lighter and full of life. 

If you stumbled upon this blog and are interested in doing therapy to address OCD, feel free to drop a line to Boreal Therapy to see how we can help you. If you are a provider that is new to working with OCD, also please feel free to give a call if you need some consultations about how to help your clients - free of charge. Either way I hope this blog post is helpful. 

-Riley