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295 Madison Avenue 12th Floor New York, NY 10017 Entrance on 41st Street drmiller@drnancymiller.com Phone: (646) 519-4527 |
Nancy Miller, Psy.D. - Licensed Clinical Psychologist
| Obsessive Compulsive Disorder: Developing a Better Understanding of the Disorder And Effective Ways to Treat It By Nancy Miller, Psy.D. |
What is OCD?
Obsessive Compulsive Disorder (OCD), an anxiety
disorder characterized by the presence of obsessions or
compulsions, or both, affects about three percent of the
population. Obsessions are unwanted, intrusive,
recurrent thoughts, impulses, or images that intrude into a
person’s mind and cause significant anxiety or distress.
For example, an obsession might be the thought, “I’m
having the thought about pushing that person off the
subway platform.” Other examples are “the shoes that I
wore outside today have dirty germs on them, so they are
dangerous,” “If I don’t pray correctly, god will punish me,”
“if I don’t repeat the last line of a song 6 times, then I will
be forever distracted by the song and I will eventually go
crazy,” “ if I don’t touch these items in a specific pattern,
something bad might happen to my parents,” and “I might
get AIDS from that subway seat and transmit it to my
girlfriend.” Compulsions are repetitive behaviors or
mental acts that a person engages in to reduce the
discomfort they experience from the obsession. Examples
of these behaviors include hand washing, checking, and
ordering. Compulsions also take the form of using mental
acts to reduce distress, like praying, counting, repeating
words, or reassuring oneself.
A person with OCD feels compelled to perform a
compulsion (i.e. a ritual) in response to an obsession, in
order to neutralize the anxiety and distress that is
generated by the obsession. Avoiding a potentially
challenging situation is also considered a compulsion.
For example, a parent avoids spending time with his child
alone to avoid the threatening obsession that he may hurt
his child. The compulsions that a person engages in to
reduce discomfort may or may not be connected to, in a
realistic way, the challenge that they are designed to
neutralize or avoid. For example, a person who suffers
with the obsession that something bad may happen to a
family member, may touch an item or may wash their
hands in a specific pattern to undo that threat.
Frequently the compulsion involves a sequence of
thoughts and/or actions that the sufferer does in a
particular order. Often rituals are excessive in nature (e.
g. washing hands 50 times a day or lengthy reassurance
seeking) and need to be performed correctly in order to
effectively neutralize distress. Rituals take up precious
time and energy, depleting the sufferer of psychological
resources. It is common to see OCD sufferers struggle
with time management. They are repeatedly late to their
scheduled activities because they were caught up
ritualizing away their anxiety. This can have serious
implications, interrupting their social and work lives.
Family members, friends, and colleagues frequently have
limited patience and unfortunately, the effects of OCD can
seriously strain relationships. When appropriate, the
family can be a part of treatment, so they can develop a
deeper understanding of the disorder and their roles in
helping the client heal.
To be diagnosed with OCD, the obsessions and/or
compulsions must cause significant distress, be time
consuming, or significantly interfere with a person’s every
day routine, work, school functioning, social activities, or
relationships. Many people engage in OCD like behaviors
such as knocking on wood to prevent something bad or
unlucky from happening or occasionally checking to see if
the stove has been turned off. These behaviors are
typically not distressing or disruptive to a person’s quality
of life. Typically, a person without OCD would not find it
very challenging to stop doing these behaviors if asked
to. A person who suffers from OCD dreads the idea of
doing something that they are afraid of and often spends
a large amount of time avoiding the OCD threat
altogether. For example, a person who is afraid of being
contaminated by germs may never use public restrooms.
When directly challenged with the OCD threat, it is
common for the OCD sufferer to seek endless
reassurance from people they are close to or to engage
in tireless efforts to collect reassuring data on the
Internet. It is also common for them to neutralize the
threat by checking their homes for up to an hour before
they leave in the morning and go to bed at night, taking
long showers while they engage in elaborate cleaning
rituals, or mentally review evidence to try to come to a
conclusion that eliminates all uncertainty and hint of
threat. For example, if a person with OCD who is afraid of
contracting AIDS sits next to an unwashed homeless
person on the subway, he may desperately seek out
reassurance from a significant other, a parent, or a friend
to try and set his mind at rest and reassure himself that
he was not exposed to the virus and that there is little to
no chance that he will contract AIDS.
The Neurobiology of OCD
While researchers have made strides with respect to
understanding the neurobiological foundation of OCD, a
great deal remains unknown. Research has focused on
the chemicals in the brain that are responsible for
transporting information, known as neurotransmitters.
The main neurotransmitter involved in OCD is Serotonin.
Several specialists have explained which brain structures
are involved in OCD and how they are accountable for
OCD symptoms. In a comprehensive explanation of the
neurobiological aspects of OCD, Fred Penzel (Penzel,
2000) explains that the premature reuptake of Serotonin
is responsible for less available Serotonin in the brain. He
further explains that when this premature reuptake
happens at multiple brain cells, there exists a brain
dysfunction. There is a strong base of evidence that
supports the notion that OCD is a biologically based
problem that involves the serotonergic system of the
brain, not a disorder of reality testing. He points to
several areas of the brain that are suspected to be the
sites where OCD symptoms originate and make up, what
he refers to as an OCD “circuit.” These brain structures
include the Orbital Cortex, Basal Ganglia, Striatum,
Caudate Nucleus, and the Thalamus. One current theory
explains that there is a dysfunction in the brain that allows
too many sensations and thoughts to leak through to
consciousness. The brain is then signaled that these
thoughts are priorities that must be acted upon and the
OCD sufferer unsuccessfully tries to suppress these
unwanted thoughts and feels anxious. Other authors
(Grayson, 2003) have explained that because of the
decrease in Serotonin, a person with OCD feels more
anxious in response to uncertainty and incompletion, and,
therefore, is compelled to respond to anxiety by trying to
escape it or avoid it. Dr. Steven Phillipson (Phillipson,
OCDONLINE.com) has called the brain’s response a
“misfiring,” implying that the OCD sufferer feels a higher
level of anxiety to intrusive material in comparison to the
non-OCD population who can easily shrug off the material
since it barely raises concern. He explains that intrusive
thoughts arbitrarily become paired with intense anxiety,
and, naturally, the sufferer tries to neutralize the
overwhelming anxiety.
In my experience treating clients with OCD, the
neurobiological predisposition to the OCD phenomenon
can be greatly influenced by a client’s belief system. If a
person experiences a great deal of distress associated
with an intrusive thought, impulse, or image, and he is
intolerant of his mind’s ability to create these intrusions (i.
e. the belief that his mind shouldn’t do this), then the
person is likely to work very hard to undo the threatening
intrusion. Cognitive based theories explain that a person
with OCD may misinterpret intrusions as having special
meaning or as signaling catastrophic danger. It is my
belief that the OCD sufferer feels intense anxiety due to
an underlying bio-vulnerability to OCD and that certain
beliefs can strengthen the challenge experienced by the
person as well as hamper his willingness to engage in
treatment. Some interfering beliefs include the
intolerance to take a small amount of risk, the intolerance
of uncertainty, the idea that one cannot make a minor
mistake, the intolerance of emotional discomfort, and the
idea that all thoughts are meaningful and must be
attended to.
The main forms of OCD
My understanding of OCD has been greatly
influenced by my mentor, Dr. Steven Phillipson, who has
an extraordinary understanding of OCD and is an
extremely gifted Psychologist. Dr. Phillipson
conceptualizes OCD as taking three predominant forms.
The first is the most well known form consisting of
obsessions and overtly observable compulsions. An
example of this would be a person who is afraid of getting
AIDS and has an array of rituals to mange this threat,
such as avoiding using the subways, avoiding public
restrooms, and washing his hands after coming into
contact with potentially contaminated items and people.
Another example of this form of OCD is a person who
repeatedly checks doors, windows, and electrical
appliances to eliminate all uncertainty of a tragedy.
A second form of OCD is referred to as “purely
obsessional” or “pure-o.” The name of this form of OCD,
“pure-o” is not face valid, since it consists of obsessions
and compulsions, but the compulsions predominately are
unobservable to the outside world since they occur mainly
in the mind of the sufferer. For example, a person with
pure-o may have the intrusive idea that they are going to
molest their baby and in response to this threatening
thought, they pray, count, or seek reassurance from
themselves and others. It is common for the sufferer to
feel extreme feelings of guilt and to believe that the OCD
is evidence that they are in some way immoral or bad.
The final form of OCD is called responsibility OCD and
involves threats about religious, ethical, or moral issues.
Often the OCD sufferer with responsibility OCD believes
that they are responsible for preventing harm to others.
For example, a person with responsibility OCD may avoid
public restrooms because they are mainly concerned with
becoming contaminated and infecting their spouse. This
may also take the form of extreme distress felt when the
person departs from what he considers to be morally
correct behavior. Also, the sufferer may experience doubt
about how acceptable he is to other people and to God.
Compulsions may include prayer, a confession, or some
other behavior that is going to undo the effect of the
“wrong.” Often the sufferer experiences extreme feeling
of guilt in response to the obsession which can be
overwhelming and debilitating.
There are several rarer conditions that fall under the
rubric of OCD, including Hoarding, Tricotillomania, Skin
Picking, and Body Dysmorphic Disorder.
Types of obsession and compulsions
While every individual’s OCD is unique and requires
an experienced clinician to develop an individual
treatment plan, many obsessions and compulsions fall
into recognizable categories. It is not uncommon for
people to start treatment confused about their symptoms,
even thinking that they are going “crazy” because of
these unwanted ideas that are occurring so frequently.
This list is not exhaustive, but is intended to give you an
idea of the types of obsessions and compulsions that
people with OCD experience:
Types of Obsessions:
Contamination
Religious
Moral Concerns
Relationship Concerns (e.g. am I in the right relationship?)
Sexuality Concerns (e.g. am I gay?)
Aggressive & Harming thoughts
Molestation thoughts
Somatic concerns
Symmetry
Types of Compulsions
Cleaning and Washing
Checking items and checking mental information
Confessing to a bad thought
Seeking reassurance from others
Reassuring one’s self
Repeating
Counting
Ordering
Praying
Replacing bad thoughts with good thoughts
Collecting information
Problem solving
Making risk assessments
Reducing the discomfort of OCD: relief at what
price?
It is well known that the non clinical population, that is
people without OCD, experience intrusive ideas that are
similar in content to OCD obsessions. As noted above,
one difference is that the non clinical population does not
experience as many intrusions and does not feel the
accompanying high level of distress that a person with
OCD feels. It is speculated that stress, both positive (e.g.
buying a new house) and negative (e.g. loosing a job) can
increase the frequency of intrusive obsessions. Since a
person with OCD experiences an elevated level of
emotions, which typically takes the form of anxiety, but
can also be guilt or anger, they naturally respond to their
anxiety by trying to remedy the situation through escaping
it in the present or avoiding it in the future. Human beings
are hard wired to respond to danger and threat with the
well documented fight or flight response. This is critical
for the sufferer to understand because many people with
OCD think that something is wrong with them since they
are caught up in a cycle of responding to or avoiding
danger. With OCD, the escape/avoidance response is
typically successful, in the short term, at reducing the
person’s uncomfortable distress. The brain is
momentarily settled, and, unfortunately, the association
between the person’s anxiety and the obsession is
strengthened. The brain becomes like a microscope,
pointing out as many future threats as it can to protect
and help the sufferer to avoid discomfort. I have worked
with many people who report experiencing 50 to 100
obsessions a day, a testimony to the OCD-brain’s mission
to continually point out all possible dangers to the
sufferer. Since the rituals successfully reduced distress in
the past, the person with OCD is more likely to use them
again in the future when faced with the challenging
obsession.
In essence, there is more than enough of a pull for
someone with OCD to respond to danger and threat by
avoiding or escaping it. First they are naturally inclined to
do so (fight or flight response) and second, the response
is negatively reinforced (it takes away the distress
temporarily). However, here is the problem: the more a
person engages in the escape and avoidance of the
potential danger put forth by his OCD, the more relevant
the OCD threat becomes, the more his brain is on the
look out for that threat, and the more conditioned his body
is to respond to the potential for danger with anxiety. In
essence, your body “jumps” with fear, irrespective of what
you know logically. This leads to an important concept in
the understanding and treatment of OCD.
Why logic does not work as a form of treatment for
OCD
While most people with OCD recognize the irrational
nature of the intrusive material, a small portion of people
with OCD have trouble recognizing that their obsessions
or compulsion are excessive and unreasonable. It has
been my experience that in the midst of a heightened
challenge, many OCD sufferers become less clear about
the irrational nature of the obsession. In other words, at
one point in treatment the person may say, “yeah, right
now I know it’s highly unlikely that because I have the
thought that my parents are going to die unless I ritualize,
that they actually will die.” However, this is often followed
by the idea “but I just can’t deal with the possibility that my
thoughts may cause them to die, and when I am
challenged, I feel so anxious and compelled to do
something about it.” Although most people who suffer
from OCD are able to recognize, to some degree, that
their behavior is excessive or unreasonable, they still feel
compelled to perform a ritual to reduce their anxiety. A
person with OCD feels significant distress, typically
anxiety, when he is confronted with his obsession.
However, he may also feel other emotions such as guilt,
anger, and depression. He may be aware that his
emotional response is disproportionate to the threat and
the threat does not make any sense, but this knowledge is
not helpful in reducing his OCD symptoms and will not
provide any long term relief. If it did, effective treatment
would take the form of educating the OCD sufferer about
the irrational nature of his fears, which has not been
shown to be effective.
Educating a person about how his beliefs interfere
with his willingness to do exposure work can be useful, but
in my experience, identifying and challenging these ideas
as the main form of OCD treatment is not helpful. OCD
has been called the disorder of doubt, because people
who have OCD experience significant distress associated
with the uncertainties that their mind reminds them of.
The sufferer is painfully attentive to any shred of
possibility that the obsessive threat may be true. For
example, a person who has the thought “I am going to
stab my wife” and counts to 50 backwards every time he
has the thought, is never fully satisfied with a logical
explanation because 100% certainty is impossible to
attain. Using logic, such as pointing out to the person that
he is a gentle natured person who has never harmed
anyone before, will only temporarily reassure and satisfy
the OCD brain. Ultimately, there is no way to ever prove
to him that he will never stab his wife. Shortly, he
encounters a trigger, such as a knife in the butcher block
and another upsetting thought slips through into his
awareness, and he is once again feeling anxious and
looking to reassure himself. The cycle grows quickly and,
as explained above, the sufferer becomes committed to a
complex web of obsession and compulsions that
strengthens the body’s anxiety reaction and the mind’s
alertness to the dangerous threat. The brain becomes a
reliable microscope that zooms in to the potential dangers
in the environment. So, while the person with OCD may
logically know that the threat is absurd or unlikely,
educating him about this is not an effective form of
treatment. In fact, focusing on the irrational nature of the
obsession is unproductive, since it serves to reassure the
sufferer and using reassurance is like pouring a tank of
gas into OCD’s engine.
Exposure and response prevention (ERP) is an
empirically supported treatment for OCD, which involves
systematically exposing the sufferer to his fears, so that
he can habituate, or get used to the threat, resulting in an
overall reduction in his distress over time. It is not a goal
of the treatment to get rid of unwanted thoughts because
experiencing them is a normal part of the brain’s
functioning, and trying to get rid of thoughts often results
in their paradoxical increase. An outcome of ERP is the
breaking of the association between the obsession and
the anxiety response. Ultimately the goal of treatment is
to learn to respond to obsessions in a therapeutic way
that will, ultimately, render the threat irrelevant, so the
brain drastically reduces its efforts to warn of the potential
dangers, and the body’s anxiety response naturally
decreases. I will discuss this intervention in the treatment
section of this article.
Helping clients to understand having OCD, is not a
reflection of who they are
It is critical in the beginning of treatment that the
sufferer begins to understand that it is natural for the
human brain to produce intrusive, upsetting, unwanted
ideas and images, and that it is not, in any way, a
reflection of who they are as a person. Many people I
have worked with feel a great sense of shame about the
nature or their OCD. Specifically, they feel ashamed of
the implications of their obsessions. They may believe
that if I have these horrible, immoral ideas, then I am a
horrible, dangerous, immoral person. Some see
themselves as defective and inferior to people who do not
suffer from OCD. They may also feel embarrassed by
their rituals, and often they become quite good at hiding
them from other people. Many people feel ashamed that
they have been unsuccessful at dealing with their OCD
and believe that they are ineffective. They also are
embarrassed of the social implications of having OCD.
They are painfully aware that people may get annoyed
when they are kept waiting due to rituals that are being
completed. Sufferers may feel misunderstood, since
many people do not understand OCD and have a limited
tolerance for the effects of ritualizing (e.g., lateness,
decreased work or school productivity, and constant
reassurance seeking).
In the beginning of therapy, it is crucial to educate the
client about how OCD develops, specifically that it is
considered to be biologically based and out of one’s
control. It is imperative to help the client to develop an in
depth understanding of the nature of OCD and to
promote a separation of who they are, including their
values, goals, and personality, from the brain’s ability to
create disturbing, unwanted, intrusive ideas. Sometimes
therapy may focus on strengthening the philosophy of
being human, with strengths and vulnerabilities, rather
than labeling oneself as “defective” or “inadequate.” I
have found it best not to argue with clients’ assessments,
rather to look closely at the utility of their old, familiar,
negative mindset about how OCD defines the type of
person that they are. This mindset is harmful and moves
clients away from their stated goals in therapy.
It is equally important to educate the client that when
faced with an OCD challenge, reminding one that “these
ideas are illogical” and “it is not me who is having these
ideas, it is my OCD” is not therapeutic because these
statements serve to reassure the client, ultimately
strengthening the disorder. I will explain more about the
counterproductive effects of using reassurance in the
treatment section of this article.
How do you treat OCD?
What is the difference between behavior therapy
and medication therapy?
Many researchers conclude that behavior therapy is
an essential part of the road to recovery for people with
OCD. Psychiatric medications, which are available only
by a prescription, may also effectively reduce OCD
symptoms. However, any improvement that is made by
taking medications is dependent on persistent use of the
medication. Additionally, medications may cause
unwanted side effects that can be discouraging. It has
been my experience that many clients are hesitant to take
medications to treat their anxiety. Fortunately, research
has demonstrated that when a person with OCD
successfully reduces his symptoms using behavioral
methods, this can result in brain modifications similar to
those seen when medication is taken (Vitek, 2009). Also,
research has demonstrated that behavior therapy can
result in a long term reduction of OCD symptoms. For
these reasons, cognitive behavioral therapy is considered
to be an essential element in treating OCD.
There are cases in which a medical evaluation is
needed. When a person is struggling with extreme
anxiety to the point they are having difficulty completing
their daily responsibilities or are not able to successfully
access treatment, medication may play an important role
in the treatment. It is most beneficial to the client when his
psychologist and prescribing physician consult each other
and are working as a team, with a common understanding
of treatment philosophy and goals, so the client does not
receive conflicting and confusing information throughout
the treatment process.
“Outwit, Outplay, Outlast”
After an initial evaluation is completed and I develop a
clear picture of the client’s symptoms and history, the first
step of treatment consists of educating the client about
OCD. This includes a review of many of the concepts that
have been described in this paper so far. It is critical that
the client embark upon the behavioral component of
treatment with a solid understanding of how OCD
develops and most importantly, how it is maintained. If
you are familiar with the reality show Survivor, the slogan
“outwit, outplay, outlast” emphasizes the importance of
understanding how OCD works. With a profound
understanding of how OCD develops and operates, the
sufferer can outwit the OCD, outplay the OCD, and
ultimately outlast the OCD. When clients understand how
OCD develops and operates, they are more willing to
participate in the behavioral treatment, which is
emotionally demanding, but a far better choice than living
with the untreated OCD. As most participants on Survivor
give 110% to their experience while on the game to
guarantee a chance at winning, I strongly suggest that
clients embark upon their psychological treatment with the
same level of devotion and commitment.
“Drop the Shovel”
In the beginning phase of treatment, another goal is to
help the client become aware of the ways in which he
attempts to avoid and escape the distress associated with
OCD. Emphasis is placed on examining if these methods
are working for the client, in terms of whether they are
moving them closer to or farther from managing their OCD
in a therapeutic way and achieving their valued life goals.
The client is encouraged to examine if efforts to deal with
OCD has led to a long term reduction in his suffering or if
he is restricting his life responding to the OCD. A
progressive form of CBT called Acceptance and
Commitment Therapy (Luoma, Hayes, & Walser, 2007)
uses a number of metaphors to foster what they call a
sense of “creative hopelessness” which is not a feeling,
but refers to the process of opening up to new
possibilities instead of trying to avoid the emotional
experience of anxiety. One potent metaphor they use
compares the client’s experience with a person who has
fallen into a hole and only has a shovel to get out. As the
person continues to use the only tool he has, his shovel,
he arduously digs himself deeper and deeper into the
hole. This metaphor highlights that the person with OCD
is putting forth a great deal of effort in trying to manage
the OCD, but is experiencing no payoff and is worsening
the situation. In this metaphor, the goal is to drop the
shovel, and use more effective techniques to manage one’
s emotional experiences.
While OCD is not a curable disorder, by engaging in
treatment, the sufferer can look forward to learning how to
manage his OCD in a way that results in a reduction in
both the intensity and frequency of the intrusive
obsessions and associated anxiety, and a life that is
dramatically improved.
What is Exposure and Response Prevention (ERP)?
When a person is hooked on using compulsions to
avoid or escape the emotional discomfort they experience
in association with the obsessive threat, the compulsion,
ultimately, prevents them from getting used to the
obsessive intrusion and the associated anxiety. The
exiting response and the avoidance response signal to
the brain that the threat needs to be pointed out
continually, and it needs to be avoided at all costs.
Choosing to ritualize to avoid or escape the feeling of
anxiety sharpens the brain’s ability to zoom in and locate
potential dangers in the environment. As mentioned
above, the person who is constantly neutralizing or
avoiding the threat altogether, never gives the brain a
chance to get used to or get bored with the threat.
Additionally, when a client completes a ritual and
experiences a reduction in distress, they are more likely to
perform that ritual again in the future.
Exposure and response prevention (ERP) is the
general term used to describe the technique of exposing
a person to the obsession while he refrains from engaging
in the neutralizing response. It is widely used to treat
OCD, and it has been shown to be the most effective form
of treatment to date. When the person exposes himself to
the threat, without engaging in the undoing response, he
will get used to, or habituate to, the threat. Once the
brain gets used to the threat, the sufferer experiences a
reduction in the obsessions and intensity of the distress.
In Dr. Phillipson’s work, he explains that the brain does
not focus on information that is continually present. This
explains why exposing oneself to the threat and accepting
the possibility of it ultimately communicates the irrelevancy
of the obsession to the brain. Once the threat becomes
irrelevant, the obsessions and distress decrease and the
brain stops to look for evidence of the threat.
How do I begin ERP?
I encourage anyone who thinks they are suffering
from OCD to meet with an experienced professional who
will complete a full evaluation and develop an
individualized treatment plan. Exposure work involves
creating a hierarchy, or a list of challenging tasks to be
worked on gradually. The treatment is highly
individualized and is best done in a cooperative alliance
with a qualified, experienced Psychologist. The
Psychologist and client agree upon exposure exercises,
which are conducted both in and out of session. The
purpose is to expose the client to the uncomfortable
situation, image, or thought, while preventing the
compulsive behavior. As time passes, the amount of
distress felt by the client decreases and habituation takes
place. The cognitive piece of the exposure work entails
rendering the threat irrelevant by taking an attitude of
accepting the threat and making room for the anxiety, as
opposed to dreading it, actively trying to stop, prevent, or
escape it. If I were to expose myself to the idea that I
might harm my children, but at the same time reassure
myself that this is unlikely, the effectiveness of the
exposure exercise would be threatened. Instead, the
most aggressive approach to the exposure would be
acknowledging the threat by saying, “Yes, I might throw
my baby over the staircase.” It is with this attitude that
one can engage in the exposure without neutralizing the
distress, and ultimately achieve the goal of habituation.
By engaging in exposure exercises frequently, the brain
has a chance to get used to the threat, and, as a
byproduct, the anxiety naturally goes down, and the brain
does not continue to look for and point out the threat
since it has become irrelevant. Once the sufferer is no
longer escaping and avoiding the threat, the brain
dramatically decreases its warning system, and the
sufferer experiences relief. The true goal of the therapy
is to take a risk that the threat may be true and let the
distress be with you. Instead of pushing the distress away
or avoiding it altogether, the ultimate goal is to learn to
tolerate the distress, making room for it to be in your
presence, so that habituation can occur.
An important concept of treatment is to understand
the difference between participating in exposure and
response prevention exercises with challenges that
naturally appear (unplanned challenges) and those that
the client plans and engages in (planned challenges). A
person who has OCD experiences unplanned challenges
throughout the day and has many opportunities to
respond to these challenges in a therapeutic way. In
response to the threat that has emerged into his
consciousness, he can take the risk of not engaging in
the ritual and tolerating the distress by riding out the
experience. He can also exaggerate the threat by using
humor, for example, acknowledging, “Yes, I am going to sit
on the subway seat that has a dark spot which might be
blood, and when I contract the disease, I’m going to
transmit it to my husband, my daughter, and then to the
whole neighborhood.”
Equally as important is the client’s willingness to
engage in challenges that he creates (planned
challenges), showing the brain that he is willing to bring
on the challenge and enhance his ability to habituate to
the threat. This is the most aggressive way to engage in
treatment, and in my experience, leads to the best
treatment outcome. The hierarchy that is built by the
therapist and the client is the road map used in therapy to
agree upon challenges that can be worked on in session
and in between sessions. Exposure might consist of
touching contaminated items, bringing up threatening
ideas, or even looking for evidence of the threat in the
environment. For example, a person who experiences an
obsession that he may molest children, might agree to
silently bring up this idea in his head, in a challenging
place, like the children’s section of a local bookstore, and
stay with the distress until it drops. A person who is afraid
of being contaminated by germs may work on touching a
bathroom doorknob in session and contaminating himself,
without washing his hands, ultimately accepting the risk
that he may get contaminated, and then continue this
exercise at home. Each time that the sufferer works on
the hierarchy, he is creating an opportunity to change the
way he typically copes with challenging situations and to
break the association between the idea and the anxiety.
Some exposure and response prevention exercises
are done “in vivo,” which means that they are overt
activities that the person engages in. For example,
turning on and off the stove, while distracting oneself,
then accepting the possibility that the stove was not
turned off correctly and a fire could erupt, may be part of
a hierarchy that addresses the threat of fire. Other ERP
exercises are “imaginal” because they are completed in
private, in one’s mind. An example of this would be a
prolonged exposure where the sufferer writes a
descriptive story capturing the threat and reads it to
himself over and over until the distress level drops
noticeably.
“Invest in Anxiety For a Calmer Future” (Eifert &
Forsyth, 2005)
To conclude, I strongly encourage anyone who thinks
they are experiencing the type of anxiety described in this
article, to contact an experienced psychologist who can
help them to get onto a road of recovery. Behavior
therapy for OCD has been shown in several controlled
studies to reduce symptoms and brain imaging studies
have shown that when symptom improvement is evident,
the changes in the brain are similar whether they are the
result of medicine or behavior therapy. The powerful
saying, “invest in anxiety for a calmer future,” illustrates
an essential concept of OCD treatment. It is necessary to
gradually confront your OCD fears to begin to overcome
them. Participating in exposure and response prevention
therapy involves gradually exposing yourself to
challenging thoughts and situations which is likely to yield
a positive and worthwhile return. Engaging in therapy is
an investment in your emotional well-being; while
challenging, it can be a rewarding and effective
experience.
References
Eifert, George & Forsyth, John. (2005). Acceptance &
Commitment Therapy for Anxiety Disorders. California:
New Harbinger Publications, Inc.
Grayson, Jonathan. (2003). Freedom From Obsessive
Compulsive Disorder. A Personalized Recovery Program
for Living with Uncertainty. New York: The Berkley
Publishing Group
Luoma, Jason, Hayes, Steven, & Walser, Robyn. (2007).
Learning ACT. California: New Harbinger Publications, Inc.
Penzel, Fred. (2000). Obsessive-Compulsive Disorder –
A Complete Guide to Getting Well and Staying Well. New
York: Oxford University Press.
Phillipson, Steven. A Prelude to Cognitive-Behavioral
Techniques For The Treatment Of OCD, from http:
//OCDONLINE.com
Vitek, Sue (2009). Obsessive Compulsive Disorder.
Cross Country Education, Inc.
Obsessive Compulsive Disorder (OCD), an anxiety
disorder characterized by the presence of obsessions or
compulsions, or both, affects about three percent of the
population. Obsessions are unwanted, intrusive,
recurrent thoughts, impulses, or images that intrude into a
person’s mind and cause significant anxiety or distress.
For example, an obsession might be the thought, “I’m
having the thought about pushing that person off the
subway platform.” Other examples are “the shoes that I
wore outside today have dirty germs on them, so they are
dangerous,” “If I don’t pray correctly, god will punish me,”
“if I don’t repeat the last line of a song 6 times, then I will
be forever distracted by the song and I will eventually go
crazy,” “ if I don’t touch these items in a specific pattern,
something bad might happen to my parents,” and “I might
get AIDS from that subway seat and transmit it to my
girlfriend.” Compulsions are repetitive behaviors or
mental acts that a person engages in to reduce the
discomfort they experience from the obsession. Examples
of these behaviors include hand washing, checking, and
ordering. Compulsions also take the form of using mental
acts to reduce distress, like praying, counting, repeating
words, or reassuring oneself.
A person with OCD feels compelled to perform a
compulsion (i.e. a ritual) in response to an obsession, in
order to neutralize the anxiety and distress that is
generated by the obsession. Avoiding a potentially
challenging situation is also considered a compulsion.
For example, a parent avoids spending time with his child
alone to avoid the threatening obsession that he may hurt
his child. The compulsions that a person engages in to
reduce discomfort may or may not be connected to, in a
realistic way, the challenge that they are designed to
neutralize or avoid. For example, a person who suffers
with the obsession that something bad may happen to a
family member, may touch an item or may wash their
hands in a specific pattern to undo that threat.
Frequently the compulsion involves a sequence of
thoughts and/or actions that the sufferer does in a
particular order. Often rituals are excessive in nature (e.
g. washing hands 50 times a day or lengthy reassurance
seeking) and need to be performed correctly in order to
effectively neutralize distress. Rituals take up precious
time and energy, depleting the sufferer of psychological
resources. It is common to see OCD sufferers struggle
with time management. They are repeatedly late to their
scheduled activities because they were caught up
ritualizing away their anxiety. This can have serious
implications, interrupting their social and work lives.
Family members, friends, and colleagues frequently have
limited patience and unfortunately, the effects of OCD can
seriously strain relationships. When appropriate, the
family can be a part of treatment, so they can develop a
deeper understanding of the disorder and their roles in
helping the client heal.
To be diagnosed with OCD, the obsessions and/or
compulsions must cause significant distress, be time
consuming, or significantly interfere with a person’s every
day routine, work, school functioning, social activities, or
relationships. Many people engage in OCD like behaviors
such as knocking on wood to prevent something bad or
unlucky from happening or occasionally checking to see if
the stove has been turned off. These behaviors are
typically not distressing or disruptive to a person’s quality
of life. Typically, a person without OCD would not find it
very challenging to stop doing these behaviors if asked
to. A person who suffers from OCD dreads the idea of
doing something that they are afraid of and often spends
a large amount of time avoiding the OCD threat
altogether. For example, a person who is afraid of being
contaminated by germs may never use public restrooms.
When directly challenged with the OCD threat, it is
common for the OCD sufferer to seek endless
reassurance from people they are close to or to engage
in tireless efforts to collect reassuring data on the
Internet. It is also common for them to neutralize the
threat by checking their homes for up to an hour before
they leave in the morning and go to bed at night, taking
long showers while they engage in elaborate cleaning
rituals, or mentally review evidence to try to come to a
conclusion that eliminates all uncertainty and hint of
threat. For example, if a person with OCD who is afraid of
contracting AIDS sits next to an unwashed homeless
person on the subway, he may desperately seek out
reassurance from a significant other, a parent, or a friend
to try and set his mind at rest and reassure himself that
he was not exposed to the virus and that there is little to
no chance that he will contract AIDS.
The Neurobiology of OCD
While researchers have made strides with respect to
understanding the neurobiological foundation of OCD, a
great deal remains unknown. Research has focused on
the chemicals in the brain that are responsible for
transporting information, known as neurotransmitters.
The main neurotransmitter involved in OCD is Serotonin.
Several specialists have explained which brain structures
are involved in OCD and how they are accountable for
OCD symptoms. In a comprehensive explanation of the
neurobiological aspects of OCD, Fred Penzel (Penzel,
2000) explains that the premature reuptake of Serotonin
is responsible for less available Serotonin in the brain. He
further explains that when this premature reuptake
happens at multiple brain cells, there exists a brain
dysfunction. There is a strong base of evidence that
supports the notion that OCD is a biologically based
problem that involves the serotonergic system of the
brain, not a disorder of reality testing. He points to
several areas of the brain that are suspected to be the
sites where OCD symptoms originate and make up, what
he refers to as an OCD “circuit.” These brain structures
include the Orbital Cortex, Basal Ganglia, Striatum,
Caudate Nucleus, and the Thalamus. One current theory
explains that there is a dysfunction in the brain that allows
too many sensations and thoughts to leak through to
consciousness. The brain is then signaled that these
thoughts are priorities that must be acted upon and the
OCD sufferer unsuccessfully tries to suppress these
unwanted thoughts and feels anxious. Other authors
(Grayson, 2003) have explained that because of the
decrease in Serotonin, a person with OCD feels more
anxious in response to uncertainty and incompletion, and,
therefore, is compelled to respond to anxiety by trying to
escape it or avoid it. Dr. Steven Phillipson (Phillipson,
OCDONLINE.com) has called the brain’s response a
“misfiring,” implying that the OCD sufferer feels a higher
level of anxiety to intrusive material in comparison to the
non-OCD population who can easily shrug off the material
since it barely raises concern. He explains that intrusive
thoughts arbitrarily become paired with intense anxiety,
and, naturally, the sufferer tries to neutralize the
overwhelming anxiety.
In my experience treating clients with OCD, the
neurobiological predisposition to the OCD phenomenon
can be greatly influenced by a client’s belief system. If a
person experiences a great deal of distress associated
with an intrusive thought, impulse, or image, and he is
intolerant of his mind’s ability to create these intrusions (i.
e. the belief that his mind shouldn’t do this), then the
person is likely to work very hard to undo the threatening
intrusion. Cognitive based theories explain that a person
with OCD may misinterpret intrusions as having special
meaning or as signaling catastrophic danger. It is my
belief that the OCD sufferer feels intense anxiety due to
an underlying bio-vulnerability to OCD and that certain
beliefs can strengthen the challenge experienced by the
person as well as hamper his willingness to engage in
treatment. Some interfering beliefs include the
intolerance to take a small amount of risk, the intolerance
of uncertainty, the idea that one cannot make a minor
mistake, the intolerance of emotional discomfort, and the
idea that all thoughts are meaningful and must be
attended to.
The main forms of OCD
My understanding of OCD has been greatly
influenced by my mentor, Dr. Steven Phillipson, who has
an extraordinary understanding of OCD and is an
extremely gifted Psychologist. Dr. Phillipson
conceptualizes OCD as taking three predominant forms.
The first is the most well known form consisting of
obsessions and overtly observable compulsions. An
example of this would be a person who is afraid of getting
AIDS and has an array of rituals to mange this threat,
such as avoiding using the subways, avoiding public
restrooms, and washing his hands after coming into
contact with potentially contaminated items and people.
Another example of this form of OCD is a person who
repeatedly checks doors, windows, and electrical
appliances to eliminate all uncertainty of a tragedy.
A second form of OCD is referred to as “purely
obsessional” or “pure-o.” The name of this form of OCD,
“pure-o” is not face valid, since it consists of obsessions
and compulsions, but the compulsions predominately are
unobservable to the outside world since they occur mainly
in the mind of the sufferer. For example, a person with
pure-o may have the intrusive idea that they are going to
molest their baby and in response to this threatening
thought, they pray, count, or seek reassurance from
themselves and others. It is common for the sufferer to
feel extreme feelings of guilt and to believe that the OCD
is evidence that they are in some way immoral or bad.
The final form of OCD is called responsibility OCD and
involves threats about religious, ethical, or moral issues.
Often the OCD sufferer with responsibility OCD believes
that they are responsible for preventing harm to others.
For example, a person with responsibility OCD may avoid
public restrooms because they are mainly concerned with
becoming contaminated and infecting their spouse. This
may also take the form of extreme distress felt when the
person departs from what he considers to be morally
correct behavior. Also, the sufferer may experience doubt
about how acceptable he is to other people and to God.
Compulsions may include prayer, a confession, or some
other behavior that is going to undo the effect of the
“wrong.” Often the sufferer experiences extreme feeling
of guilt in response to the obsession which can be
overwhelming and debilitating.
There are several rarer conditions that fall under the
rubric of OCD, including Hoarding, Tricotillomania, Skin
Picking, and Body Dysmorphic Disorder.
Types of obsession and compulsions
While every individual’s OCD is unique and requires
an experienced clinician to develop an individual
treatment plan, many obsessions and compulsions fall
into recognizable categories. It is not uncommon for
people to start treatment confused about their symptoms,
even thinking that they are going “crazy” because of
these unwanted ideas that are occurring so frequently.
This list is not exhaustive, but is intended to give you an
idea of the types of obsessions and compulsions that
people with OCD experience:
Types of Obsessions:
Contamination
Religious
Moral Concerns
Relationship Concerns (e.g. am I in the right relationship?)
Sexuality Concerns (e.g. am I gay?)
Aggressive & Harming thoughts
Molestation thoughts
Somatic concerns
Symmetry
Types of Compulsions
Cleaning and Washing
Checking items and checking mental information
Confessing to a bad thought
Seeking reassurance from others
Reassuring one’s self
Repeating
Counting
Ordering
Praying
Replacing bad thoughts with good thoughts
Collecting information
Problem solving
Making risk assessments
Reducing the discomfort of OCD: relief at what
price?
It is well known that the non clinical population, that is
people without OCD, experience intrusive ideas that are
similar in content to OCD obsessions. As noted above,
one difference is that the non clinical population does not
experience as many intrusions and does not feel the
accompanying high level of distress that a person with
OCD feels. It is speculated that stress, both positive (e.g.
buying a new house) and negative (e.g. loosing a job) can
increase the frequency of intrusive obsessions. Since a
person with OCD experiences an elevated level of
emotions, which typically takes the form of anxiety, but
can also be guilt or anger, they naturally respond to their
anxiety by trying to remedy the situation through escaping
it in the present or avoiding it in the future. Human beings
are hard wired to respond to danger and threat with the
well documented fight or flight response. This is critical
for the sufferer to understand because many people with
OCD think that something is wrong with them since they
are caught up in a cycle of responding to or avoiding
danger. With OCD, the escape/avoidance response is
typically successful, in the short term, at reducing the
person’s uncomfortable distress. The brain is
momentarily settled, and, unfortunately, the association
between the person’s anxiety and the obsession is
strengthened. The brain becomes like a microscope,
pointing out as many future threats as it can to protect
and help the sufferer to avoid discomfort. I have worked
with many people who report experiencing 50 to 100
obsessions a day, a testimony to the OCD-brain’s mission
to continually point out all possible dangers to the
sufferer. Since the rituals successfully reduced distress in
the past, the person with OCD is more likely to use them
again in the future when faced with the challenging
obsession.
In essence, there is more than enough of a pull for
someone with OCD to respond to danger and threat by
avoiding or escaping it. First they are naturally inclined to
do so (fight or flight response) and second, the response
is negatively reinforced (it takes away the distress
temporarily). However, here is the problem: the more a
person engages in the escape and avoidance of the
potential danger put forth by his OCD, the more relevant
the OCD threat becomes, the more his brain is on the
look out for that threat, and the more conditioned his body
is to respond to the potential for danger with anxiety. In
essence, your body “jumps” with fear, irrespective of what
you know logically. This leads to an important concept in
the understanding and treatment of OCD.
Why logic does not work as a form of treatment for
OCD
While most people with OCD recognize the irrational
nature of the intrusive material, a small portion of people
with OCD have trouble recognizing that their obsessions
or compulsion are excessive and unreasonable. It has
been my experience that in the midst of a heightened
challenge, many OCD sufferers become less clear about
the irrational nature of the obsession. In other words, at
one point in treatment the person may say, “yeah, right
now I know it’s highly unlikely that because I have the
thought that my parents are going to die unless I ritualize,
that they actually will die.” However, this is often followed
by the idea “but I just can’t deal with the possibility that my
thoughts may cause them to die, and when I am
challenged, I feel so anxious and compelled to do
something about it.” Although most people who suffer
from OCD are able to recognize, to some degree, that
their behavior is excessive or unreasonable, they still feel
compelled to perform a ritual to reduce their anxiety. A
person with OCD feels significant distress, typically
anxiety, when he is confronted with his obsession.
However, he may also feel other emotions such as guilt,
anger, and depression. He may be aware that his
emotional response is disproportionate to the threat and
the threat does not make any sense, but this knowledge is
not helpful in reducing his OCD symptoms and will not
provide any long term relief. If it did, effective treatment
would take the form of educating the OCD sufferer about
the irrational nature of his fears, which has not been
shown to be effective.
Educating a person about how his beliefs interfere
with his willingness to do exposure work can be useful, but
in my experience, identifying and challenging these ideas
as the main form of OCD treatment is not helpful. OCD
has been called the disorder of doubt, because people
who have OCD experience significant distress associated
with the uncertainties that their mind reminds them of.
The sufferer is painfully attentive to any shred of
possibility that the obsessive threat may be true. For
example, a person who has the thought “I am going to
stab my wife” and counts to 50 backwards every time he
has the thought, is never fully satisfied with a logical
explanation because 100% certainty is impossible to
attain. Using logic, such as pointing out to the person that
he is a gentle natured person who has never harmed
anyone before, will only temporarily reassure and satisfy
the OCD brain. Ultimately, there is no way to ever prove
to him that he will never stab his wife. Shortly, he
encounters a trigger, such as a knife in the butcher block
and another upsetting thought slips through into his
awareness, and he is once again feeling anxious and
looking to reassure himself. The cycle grows quickly and,
as explained above, the sufferer becomes committed to a
complex web of obsession and compulsions that
strengthens the body’s anxiety reaction and the mind’s
alertness to the dangerous threat. The brain becomes a
reliable microscope that zooms in to the potential dangers
in the environment. So, while the person with OCD may
logically know that the threat is absurd or unlikely,
educating him about this is not an effective form of
treatment. In fact, focusing on the irrational nature of the
obsession is unproductive, since it serves to reassure the
sufferer and using reassurance is like pouring a tank of
gas into OCD’s engine.
Exposure and response prevention (ERP) is an
empirically supported treatment for OCD, which involves
systematically exposing the sufferer to his fears, so that
he can habituate, or get used to the threat, resulting in an
overall reduction in his distress over time. It is not a goal
of the treatment to get rid of unwanted thoughts because
experiencing them is a normal part of the brain’s
functioning, and trying to get rid of thoughts often results
in their paradoxical increase. An outcome of ERP is the
breaking of the association between the obsession and
the anxiety response. Ultimately the goal of treatment is
to learn to respond to obsessions in a therapeutic way
that will, ultimately, render the threat irrelevant, so the
brain drastically reduces its efforts to warn of the potential
dangers, and the body’s anxiety response naturally
decreases. I will discuss this intervention in the treatment
section of this article.
Helping clients to understand having OCD, is not a
reflection of who they are
It is critical in the beginning of treatment that the
sufferer begins to understand that it is natural for the
human brain to produce intrusive, upsetting, unwanted
ideas and images, and that it is not, in any way, a
reflection of who they are as a person. Many people I
have worked with feel a great sense of shame about the
nature or their OCD. Specifically, they feel ashamed of
the implications of their obsessions. They may believe
that if I have these horrible, immoral ideas, then I am a
horrible, dangerous, immoral person. Some see
themselves as defective and inferior to people who do not
suffer from OCD. They may also feel embarrassed by
their rituals, and often they become quite good at hiding
them from other people. Many people feel ashamed that
they have been unsuccessful at dealing with their OCD
and believe that they are ineffective. They also are
embarrassed of the social implications of having OCD.
They are painfully aware that people may get annoyed
when they are kept waiting due to rituals that are being
completed. Sufferers may feel misunderstood, since
many people do not understand OCD and have a limited
tolerance for the effects of ritualizing (e.g., lateness,
decreased work or school productivity, and constant
reassurance seeking).
In the beginning of therapy, it is crucial to educate the
client about how OCD develops, specifically that it is
considered to be biologically based and out of one’s
control. It is imperative to help the client to develop an in
depth understanding of the nature of OCD and to
promote a separation of who they are, including their
values, goals, and personality, from the brain’s ability to
create disturbing, unwanted, intrusive ideas. Sometimes
therapy may focus on strengthening the philosophy of
being human, with strengths and vulnerabilities, rather
than labeling oneself as “defective” or “inadequate.” I
have found it best not to argue with clients’ assessments,
rather to look closely at the utility of their old, familiar,
negative mindset about how OCD defines the type of
person that they are. This mindset is harmful and moves
clients away from their stated goals in therapy.
It is equally important to educate the client that when
faced with an OCD challenge, reminding one that “these
ideas are illogical” and “it is not me who is having these
ideas, it is my OCD” is not therapeutic because these
statements serve to reassure the client, ultimately
strengthening the disorder. I will explain more about the
counterproductive effects of using reassurance in the
treatment section of this article.
How do you treat OCD?
What is the difference between behavior therapy
and medication therapy?
Many researchers conclude that behavior therapy is
an essential part of the road to recovery for people with
OCD. Psychiatric medications, which are available only
by a prescription, may also effectively reduce OCD
symptoms. However, any improvement that is made by
taking medications is dependent on persistent use of the
medication. Additionally, medications may cause
unwanted side effects that can be discouraging. It has
been my experience that many clients are hesitant to take
medications to treat their anxiety. Fortunately, research
has demonstrated that when a person with OCD
successfully reduces his symptoms using behavioral
methods, this can result in brain modifications similar to
those seen when medication is taken (Vitek, 2009). Also,
research has demonstrated that behavior therapy can
result in a long term reduction of OCD symptoms. For
these reasons, cognitive behavioral therapy is considered
to be an essential element in treating OCD.
There are cases in which a medical evaluation is
needed. When a person is struggling with extreme
anxiety to the point they are having difficulty completing
their daily responsibilities or are not able to successfully
access treatment, medication may play an important role
in the treatment. It is most beneficial to the client when his
psychologist and prescribing physician consult each other
and are working as a team, with a common understanding
of treatment philosophy and goals, so the client does not
receive conflicting and confusing information throughout
the treatment process.
“Outwit, Outplay, Outlast”
After an initial evaluation is completed and I develop a
clear picture of the client’s symptoms and history, the first
step of treatment consists of educating the client about
OCD. This includes a review of many of the concepts that
have been described in this paper so far. It is critical that
the client embark upon the behavioral component of
treatment with a solid understanding of how OCD
develops and most importantly, how it is maintained. If
you are familiar with the reality show Survivor, the slogan
“outwit, outplay, outlast” emphasizes the importance of
understanding how OCD works. With a profound
understanding of how OCD develops and operates, the
sufferer can outwit the OCD, outplay the OCD, and
ultimately outlast the OCD. When clients understand how
OCD develops and operates, they are more willing to
participate in the behavioral treatment, which is
emotionally demanding, but a far better choice than living
with the untreated OCD. As most participants on Survivor
give 110% to their experience while on the game to
guarantee a chance at winning, I strongly suggest that
clients embark upon their psychological treatment with the
same level of devotion and commitment.
“Drop the Shovel”
In the beginning phase of treatment, another goal is to
help the client become aware of the ways in which he
attempts to avoid and escape the distress associated with
OCD. Emphasis is placed on examining if these methods
are working for the client, in terms of whether they are
moving them closer to or farther from managing their OCD
in a therapeutic way and achieving their valued life goals.
The client is encouraged to examine if efforts to deal with
OCD has led to a long term reduction in his suffering or if
he is restricting his life responding to the OCD. A
progressive form of CBT called Acceptance and
Commitment Therapy (Luoma, Hayes, & Walser, 2007)
uses a number of metaphors to foster what they call a
sense of “creative hopelessness” which is not a feeling,
but refers to the process of opening up to new
possibilities instead of trying to avoid the emotional
experience of anxiety. One potent metaphor they use
compares the client’s experience with a person who has
fallen into a hole and only has a shovel to get out. As the
person continues to use the only tool he has, his shovel,
he arduously digs himself deeper and deeper into the
hole. This metaphor highlights that the person with OCD
is putting forth a great deal of effort in trying to manage
the OCD, but is experiencing no payoff and is worsening
the situation. In this metaphor, the goal is to drop the
shovel, and use more effective techniques to manage one’
s emotional experiences.
While OCD is not a curable disorder, by engaging in
treatment, the sufferer can look forward to learning how to
manage his OCD in a way that results in a reduction in
both the intensity and frequency of the intrusive
obsessions and associated anxiety, and a life that is
dramatically improved.
What is Exposure and Response Prevention (ERP)?
When a person is hooked on using compulsions to
avoid or escape the emotional discomfort they experience
in association with the obsessive threat, the compulsion,
ultimately, prevents them from getting used to the
obsessive intrusion and the associated anxiety. The
exiting response and the avoidance response signal to
the brain that the threat needs to be pointed out
continually, and it needs to be avoided at all costs.
Choosing to ritualize to avoid or escape the feeling of
anxiety sharpens the brain’s ability to zoom in and locate
potential dangers in the environment. As mentioned
above, the person who is constantly neutralizing or
avoiding the threat altogether, never gives the brain a
chance to get used to or get bored with the threat.
Additionally, when a client completes a ritual and
experiences a reduction in distress, they are more likely to
perform that ritual again in the future.
Exposure and response prevention (ERP) is the
general term used to describe the technique of exposing
a person to the obsession while he refrains from engaging
in the neutralizing response. It is widely used to treat
OCD, and it has been shown to be the most effective form
of treatment to date. When the person exposes himself to
the threat, without engaging in the undoing response, he
will get used to, or habituate to, the threat. Once the
brain gets used to the threat, the sufferer experiences a
reduction in the obsessions and intensity of the distress.
In Dr. Phillipson’s work, he explains that the brain does
not focus on information that is continually present. This
explains why exposing oneself to the threat and accepting
the possibility of it ultimately communicates the irrelevancy
of the obsession to the brain. Once the threat becomes
irrelevant, the obsessions and distress decrease and the
brain stops to look for evidence of the threat.
How do I begin ERP?
I encourage anyone who thinks they are suffering
from OCD to meet with an experienced professional who
will complete a full evaluation and develop an
individualized treatment plan. Exposure work involves
creating a hierarchy, or a list of challenging tasks to be
worked on gradually. The treatment is highly
individualized and is best done in a cooperative alliance
with a qualified, experienced Psychologist. The
Psychologist and client agree upon exposure exercises,
which are conducted both in and out of session. The
purpose is to expose the client to the uncomfortable
situation, image, or thought, while preventing the
compulsive behavior. As time passes, the amount of
distress felt by the client decreases and habituation takes
place. The cognitive piece of the exposure work entails
rendering the threat irrelevant by taking an attitude of
accepting the threat and making room for the anxiety, as
opposed to dreading it, actively trying to stop, prevent, or
escape it. If I were to expose myself to the idea that I
might harm my children, but at the same time reassure
myself that this is unlikely, the effectiveness of the
exposure exercise would be threatened. Instead, the
most aggressive approach to the exposure would be
acknowledging the threat by saying, “Yes, I might throw
my baby over the staircase.” It is with this attitude that
one can engage in the exposure without neutralizing the
distress, and ultimately achieve the goal of habituation.
By engaging in exposure exercises frequently, the brain
has a chance to get used to the threat, and, as a
byproduct, the anxiety naturally goes down, and the brain
does not continue to look for and point out the threat
since it has become irrelevant. Once the sufferer is no
longer escaping and avoiding the threat, the brain
dramatically decreases its warning system, and the
sufferer experiences relief. The true goal of the therapy
is to take a risk that the threat may be true and let the
distress be with you. Instead of pushing the distress away
or avoiding it altogether, the ultimate goal is to learn to
tolerate the distress, making room for it to be in your
presence, so that habituation can occur.
An important concept of treatment is to understand
the difference between participating in exposure and
response prevention exercises with challenges that
naturally appear (unplanned challenges) and those that
the client plans and engages in (planned challenges). A
person who has OCD experiences unplanned challenges
throughout the day and has many opportunities to
respond to these challenges in a therapeutic way. In
response to the threat that has emerged into his
consciousness, he can take the risk of not engaging in
the ritual and tolerating the distress by riding out the
experience. He can also exaggerate the threat by using
humor, for example, acknowledging, “Yes, I am going to sit
on the subway seat that has a dark spot which might be
blood, and when I contract the disease, I’m going to
transmit it to my husband, my daughter, and then to the
whole neighborhood.”
Equally as important is the client’s willingness to
engage in challenges that he creates (planned
challenges), showing the brain that he is willing to bring
on the challenge and enhance his ability to habituate to
the threat. This is the most aggressive way to engage in
treatment, and in my experience, leads to the best
treatment outcome. The hierarchy that is built by the
therapist and the client is the road map used in therapy to
agree upon challenges that can be worked on in session
and in between sessions. Exposure might consist of
touching contaminated items, bringing up threatening
ideas, or even looking for evidence of the threat in the
environment. For example, a person who experiences an
obsession that he may molest children, might agree to
silently bring up this idea in his head, in a challenging
place, like the children’s section of a local bookstore, and
stay with the distress until it drops. A person who is afraid
of being contaminated by germs may work on touching a
bathroom doorknob in session and contaminating himself,
without washing his hands, ultimately accepting the risk
that he may get contaminated, and then continue this
exercise at home. Each time that the sufferer works on
the hierarchy, he is creating an opportunity to change the
way he typically copes with challenging situations and to
break the association between the idea and the anxiety.
Some exposure and response prevention exercises
are done “in vivo,” which means that they are overt
activities that the person engages in. For example,
turning on and off the stove, while distracting oneself,
then accepting the possibility that the stove was not
turned off correctly and a fire could erupt, may be part of
a hierarchy that addresses the threat of fire. Other ERP
exercises are “imaginal” because they are completed in
private, in one’s mind. An example of this would be a
prolonged exposure where the sufferer writes a
descriptive story capturing the threat and reads it to
himself over and over until the distress level drops
noticeably.
“Invest in Anxiety For a Calmer Future” (Eifert &
Forsyth, 2005)
To conclude, I strongly encourage anyone who thinks
they are experiencing the type of anxiety described in this
article, to contact an experienced psychologist who can
help them to get onto a road of recovery. Behavior
therapy for OCD has been shown in several controlled
studies to reduce symptoms and brain imaging studies
have shown that when symptom improvement is evident,
the changes in the brain are similar whether they are the
result of medicine or behavior therapy. The powerful
saying, “invest in anxiety for a calmer future,” illustrates
an essential concept of OCD treatment. It is necessary to
gradually confront your OCD fears to begin to overcome
them. Participating in exposure and response prevention
therapy involves gradually exposing yourself to
challenging thoughts and situations which is likely to yield
a positive and worthwhile return. Engaging in therapy is
an investment in your emotional well-being; while
challenging, it can be a rewarding and effective
experience.
References
Eifert, George & Forsyth, John. (2005). Acceptance &
Commitment Therapy for Anxiety Disorders. California:
New Harbinger Publications, Inc.
Grayson, Jonathan. (2003). Freedom From Obsessive
Compulsive Disorder. A Personalized Recovery Program
for Living with Uncertainty. New York: The Berkley
Publishing Group
Luoma, Jason, Hayes, Steven, & Walser, Robyn. (2007).
Learning ACT. California: New Harbinger Publications, Inc.
Penzel, Fred. (2000). Obsessive-Compulsive Disorder –
A Complete Guide to Getting Well and Staying Well. New
York: Oxford University Press.
Phillipson, Steven. A Prelude to Cognitive-Behavioral
Techniques For The Treatment Of OCD, from http:
//OCDONLINE.com
Vitek, Sue (2009). Obsessive Compulsive Disorder.
Cross Country Education, Inc.
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