What is Obsessive Compulsive Disorder?
Overview
Obsessive Compulsive Disorder is a chronic condition in which a person has uncontrollable, reoccurring thoughts (known as obsessions) and/or behaviors (known as compulsions) that he/she/they feel the urge to repeat over and over again.
According to the National Institute of Mental Health (NIMH), 1.2% of adults residing in the United States reported having OCD in any given year. Rates of OCD were found to be higher among women than men; however, men demonstrate symptoms earlier than women. Symptoms can begin as early as 4 years old and continue into adulthood. Over 50% of adults with OCD reported serious impairment. Majority (90%) of people with OCD experience a co-occurring disorder such as an anxiety or mood disorder. Medication known as SSRI’s are used to treat OCD, reporting an average success rate of 50%. The combination of medication and CBT (Cognitive Behavioral Therapy) has been found to be successful. ERP (Exposure Response Prevention) in conjunction with an SSRI is also beneficial in reducing symptoms of OCD. Habit Reversal Therapy has shown to be effective in treating disorders such as skin picking.
Obsessions
Obsessions are repetitive thoughts, impulses, or mental images that result in distress or anxiety for the person as these symptoms are difficult to control.
Compulsions
Compulsions are the repetitive actions or behaviors a person feels compelled to perform in response to an obsessive thought in the interest of abating anxiety.
Less Common Subtypes of OCD
Some decades ago, OCD symptoms consisted mainly of contamination or germ issues, harm issues, and organization or symmetry issues, followed by corresponding compulsions such as checking or hand washing. As OCD evolved, researchers began to identify and study new subtypes of OCD such as HOCD (homosexual), ROCD (relationship), TOCD (transgender), Sensorimotor OCD and very recently, Ocular Tourettic OCD (repeatedly staring at objects in the periphery of one’s vision or at socially inappropriate parts of other people’s bodies). Often these more recent subtypes of OCD are overlooked, misunderstood, or inaccurately diagnosed by professionals. Thereby, resulting in years of frustration and disappointment for those struggling to manage symptoms without the proper assistance.
What is Sexual Orientation OCD also known as Homosexual OCD?
What is Relationship OCD?
Overview of Common Types of OCD
Contamination & Germ Obsessions
A person with contamination symptoms is fearful of becoming contaminated by coming into contact with someone or something or contaminating someone else with a real or imagined “thing.” Real contaminations include bacteria, viruses, bodily fluids, or harmful/toxic chemicals. Imagined “contaminations” include bad luck, unlucky people, or people with a noncontagious condition.
Harm (Sexual and/or Violent) Obsessions
Violent or inappropriate thoughts may involve mental images of causing harm to oneself but more often another living being. Typically, the most significant people or animals in our lives are the subject of these images, making for a distressing situation for the person experiencing these obsessions. It is important to remember that although people feel an urge or impulse to act on these images, people do not act on such images because they have no actual desire to do so. Common impulses or images I have heard from clients consist of a thought to “run my car into the divider while driving” or “drive off the bridge” or “hit a crossing pedestrian while waiting at a red light.” Some clients also report sexually inappropriate and often scary images to act aggressively towards a parent, sibling, or partner. None of these reports are unique and I work closely with the client to reduce feelings of embarrassment and shame surrounding these images.
Order & Symmetry or “Just Right” Obsessions
The alignment or exactness of an inanimate or an animate object is necessary for the person to feel the circumstance is “right.” This may include arranging items on a desk in a certain order, counting only by even or odd numbers, scheduling appointments only on the half hour mark, or following weather patterns. There is an irrational, overemphasis on getting it to feel “correct” or “right." As a result of this need to achieve perfection, it can be challenging for the person to proceed with the day without stopping to “correct” the many, different things that catch their attention. Interpersonal conflict can often result when the person is rigid and unable to control their need to rearrange something at the expense of their relationship.
Moral or Religious, Scrupulosity Obsessions
The hyper focus on following rules, guidelines, laws, and procedures in a literal context at all times epitomes this OCD subtype. Individuals struggle with concerns about “doing the right thing” all the time to avoid premature death, hell, sinning, or other perceived catastrophic events. There is a tendency to turn to God and prayer in an unhealthy manner when a person believes they have sinned or conducted themselves in an unethical or immoral manner. Parents with this type of OCD may inadvertently parent their children in such a way so as to impose these symptoms onto their children resulting in the development of children displaying similar traits and actions.
Common Compulsions
Compulsive Responses to Obsessive Thoughts
Compulsions are the actions taken by the individual in response to the provoking thought or mental image in the interest of reducing distress or anxiety. For example, people who engage in checking behavior are attempting to alleviate unwanted thoughts centering on safety or harm. More specifically, people who check the stove, front door, car battery, or crosswalk for pediatricians are attempting to ensure that they unequivocally have not harmed someone else, themselves, or a loved pet. This often leads to mental rituals, repetitive self-talk, and reassurance seeking behavior from people around them with the intention of ensuring a safe outcome was achieved. Other compulsive acts may consist of speaking with a priest or going to confession in response to moral (or scrupulosity) obsessions. Participating in charity work or making donations are also done to abate feelings of “being wrong or dirty.” Hand washing is a common response to contamination obsessions. Avoiding hospitals, doctor’s offices, or other locations where bacteria and viruses can often be found are also compulsive acts. Rearranging, reordering, and organizing items repeatedly are compulsions done to reduce obsessional thoughts centering on order and symmetry. In addition, typing and retyping emails, text messages, and written assignments are more current versions of managing “just right” obsessions. Lastly, avoidance of loved ones, children, or animals is done to protect any of these vulnerable populations from the possibility of acting out violently or sexually inappropriately. This may include declining attending social functions or avoiding watching or reading material with sexual content while in the presence of someone or something that may be triggering. If these obsessive thoughts are severe, a person may entirely avoid relationships and having children to guarantee their safety. It is important to recall that people do not act on these thoughts when experienced in the context of OCD symptoms.
Compulsions pertaining to the more current OCD subtypes such as HOCD, ROCD, TOCD, Sensorimotor OCD, or “Pure O-OCD” are better suited for 1-on-1 discussions with a trained professional such as myself given that the obsessive thoughts associated with each subtype can often be misunderstood from online content, resulting in further impairment and distress.
COVID-19 & OBSESSIVE COMPULSIVE DISORDER
Contamination & Covid
During the early stages of the pandemic, many people diagnosed with OCD began to experience an increase in the severity of their contamination obsessions. This resulted in the necessity to engage in the compulsive act of handwashing. Many people used copious amounts of hand sanitizer when access to a sink with hot water and disinfecting soap was not available. Some relied on wearing latex gloves while navigating local stores for essentials. And some simply did not leave their house for fear of contamination and subsequent illness.
I have worked closely with my clients over the past year implementing ERP techniques, directly addressing problematic and distressing thoughts pertaining to contamination, health, and safety. Cognitive Behavioral Therapy augments our work so that clients learn how to reframe unhelpful thinking patterns. Through the use of weekly (biweekly if indicated) exposures, I have watched clients drastically improve their need to compulsively wash their hands. Many have since returned to “real-world” settings, armed with the skills they learned in treatment.
Fear of Harming Others
Managing thoughts that you may have harmed a loved one or pet during pre-Covid conditions presented challenges. Since the pandemic uprooted our worlds in March of 2020, it has presented a unique set of challenges for those experiencing obsessions centering on harm and safety. The idea that you could infect a loved one with a potentially fatal disease is overwhelming, scary, and, technically, impossible to entirely prevent from happening.
My clients have experienced a combination of “just right” thoughts coupled with harming thoughts, exacerbating their pre-existing condition. Following recommended CDC and FDA guidelines on how to protect oneself and others from contracting the virus is a good first step in learning how to successfully function in a pandemic. However, these guidelines established by the experts are not 100% full proof-things may still go awry. As a result, it’s impossible to guarantee good health despite a client’s efforts at following protocols perfectly. My clients have learned how to address their pursuit of perfection and thoughts of harming others so that they may live more realistically in response to the current conditions.
Covid-19: Problem or Opportunity?
The Journal of Anxiety Disorders published a study in January of 2021…..
Additional Specialties
Social Anxiety
Social Anxiety, or Social Phobia, is the chronic fear of being in a social situation whereby you may be scrutinized or judged by others or the fear that you may conduct yourself in an embarrassing manner and experience shame or humiliation. One in 10 people experience social anxiety at some point during their lives. Social anxiety generally begins in childhood and may advance into adulthood if untreated, impacting relationships, careers, and everyday activities.
Research has shown that CBT is one of the most effective treatments in reducing the phobic avoidance a person experiences with social anxiety. Exploration of distorted thinking patterns that lead to avoidant behaviors are at the crux of Cognitive Behavioral Therapy. ERP may also be considered to address social anxiety by gradually exposing the person to the feared stimuli while helping he/she/them learn how to manage discomfort and uncertainty.
Panic Disorder
Spontaneous or uncued panic attacks occur without warning or an identified trigger while situational or cued attacks are prompted by an actual or anticipated environmental exposure. Panic attacks prompt physical and cognitive symptoms in the form of a racing heart, dizziness, or lightheadedness, shaking, sweating, chest pain, cramping, shortness of breath, or a feeling of detachment or disorientation. Thoughts commonly associated with panic attacks center on a fear of losing control, dying, or acting impulsively and hurting someone. Panic attacks can happen just about anywhere.
Lesser-known panic attacks are called Nocturnal Panic Attacks which often occur during late Stage 2 and early Stage 3 sleep. Sleep terrors may occur during Stage 4 sleep while nightmares often occur during REM sleep. NPA are not the same as night terrors or nightmares. NPA often wake the person up to a sudden feeling of dread or fright for unknown reasons. Anecdotally speaking, clients have reported NPA between 1:30am and 3:30am when our bodies are at their weakest points.
Deep breathing (if possible), guided imagery, or muscle relaxation techniques are used to treat panic attacks. In addition, visualization, and grounding techniques are taught to help abate physical symptoms associated with an attack.
GAD & Phobias
Generalized Anxiety Disorder as well as Specific Phobias are common co-occurring disorders clients experience. Generalized Anxiety Disorder is a chronic, non-discriminatory, free-floating anxiety that is experienced like a sense of impending doom or a fear of something bad happening. Often people with GAD are labeled as “worriers,” who find it difficult to achieve a sense of calmness and contentment. The person experiences both disturbing physical and mental symptoms comparable to other anxiety disorders.
Specific Phobias is a persistent irrational, fear in response to a specific trigger. Triggers may include a fear of elevators, heights, snakes, spiders, open spaces, or crowds (Agoraphobia), blood, needles, animals/dogs, social situation, or public speaking. As a result, a person might limit their experiences or opportunities in an effort to avoid the likelihood of encountering his/her/their specific phobia.
Similar to the other anxiety disorders, CBT techniques are utilized to address problematic symptoms. Exposure Response Prevention Therapy is also used to address phobias. ERP consists of a number of weekly sessions whereby the person gradually exposes themselves to the feared stimuli in an effort to overcome the anxiety prompted by the phobia. Lastly, medication management can be utilized if necessary.
Hoarding
Hoarding is the difficulty in discarding of or giving away personal items due to an irrational, perceived need to save them often for later use. Signs of Hoarding behavior include acquiring items that aren’t practically or otherwise needed and not having reasonable space to put them in, difficulty throwing out or giving away personal possessions, feeling upset about the idea of getting rid of personal items, and having a tendency towards perfectionism, procrastination, indecisiveness, as well as problems with organization and planning. Hoarding behavior ranges from mild to severe resulting in minimal impairment to a person’s daily life or severe impairment in the form of fractured relationships, an inability to function at work, and safety hazards in the form of a potential fire in the home. Typically, I can conduct a home visit to evaluate for the likelihood of hoarding behavior. *Due to Covid-19, I am making infrequent visits to households. If you are seeking help for Hoarding, please contact me to discuss how to best approach your treatment needs under the current circumstances.
Skin Picking & Trichotillomania/Hair Pulling
The Urge to Pick
Skin picking, also known as neurotic excoriation, is a common Body Focused Repetitive Behavior like hair pulling and nail biting. It is an impulsive behavior that is performed in an unconscious manner in response to something that does not look or feel “just right” on the skin. A scab, an ingrown hair, an open pore, or a barely observable bump can result in a person picking under the layers of skin to "fix" the perceived problem or imperfection. This compulsive behavior can cause scarring, pock marks, red spots, and bleeding. Often clients report feeling embarrassed or shameful due to the time they spent on the behavior and the damage they created on their body. Many people who struggle with this problem feel isolated and alone as well as misunderstood, often trying to hide the issue from loved ones. ERP and/or Habit Reversal Training is used to treat problematic skin picking as well as Trichotillomania. There are 4 main components of HRT.
Awareness Training
The person learns to identify the earliest warning that a tic or impulsive behavior is about to take place. These warning signs can be urges, sensations, or thoughts.
The person identifies all the situations during which the tic or impulsive behavior occurs.
Development of a Competing Response
The competing response is opposite that of the tic or impulsive behavior and is something that can be carried out for longer than just a couple of minutes.
For example, a competing response to hair-pulling might be to ball the hands into a fist and hold them rigidly alongside the body. It should be an action other people are unlikely to notice.
Building Motivation
The person is directed to make a list of the problems prompted by the behavior to prevent the behavior from coming back. The list should be discussed with trusted friends and family so that they may be supportive while offering praise.
Generalization of New Skills
In this final stage, the person is encouraged to repeatedly practice the skills they have learned in “real world” settings. The goal is to translate your skills beyond the professional’s office.