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The Many Guises of OCD
Psychotherapy Networker
Published: Nov/Dec 2014
by Martin Seif and Sally Winston

Q: As a therapist trained in traditional talk therapy, I find work with OCD clients difficult and frustrating. Can you offer guidelines about the principles of effective treatment?

A: The past 3 decades have seen a revolution in the understanding and treatment of obsessive compulsive disorder (OCD). In the early 1980s, OCD was thought to be rare, and there were no established best methods for treatment; however, we now understand OCD to be quite common, and a clearer understanding of its nature has led to the development of effective treatments, especially exposure and response prevention (ERP), sometimes called exposure and ritual prevention. Additionally, the introduction of effective psychopharmacology has broadened the range of people with this disorder who can be helped.

Understanding OCD begins with grasping the similarities and differences among the phenomena that comprise it. Obsessions are repetitive thoughts or images that feel uncontrollable, threatening, repulsive, or shocking. They arrive in a whoosh, accompanied by an urge to avoid or remove them. Compulsions are actions or thoughts that function temporarily to lower anxiety. It's easy to recognize behavioral compulsions like cleaning and checking, but purely mental compulsions are far more common and important than previously understood. Mental compulsions include counting rituals, memory checking, distractions, ritualized prayer, and self-reassurances. Clients will often refer to their mental compulsions as rationalizing or analyzing or even problem-solving. Since mental compulsions often go unnoticed, you're probably seeing more people with OCD than you think.

Many people with OCD aren't easy to diagnose. People with unwanted intrusive thoughts of causing harm, violence, or suicide invariably engage in internal attempts to suppress, avoid, or counteract these thoughts. They describe themselves as having these thoughts stuck in their mind, and they worry what the thoughts mean about their character and whether they might act on any of them. People with the form of OCD called scrupulosity, or overblown-conscience OCD, engage in mental rituals consisting of internal conversations about responsibility, good and evil, and right and wrong. And those who suffer from pathological-doubt OCD pose themselves unanswerable questions—such as "How can I know my reality is the same as yours?" or "What happens after death?" or "How can I be sure my loved ones are safe?"—and then engage in tortuous attempts to find certainty where it can't exist.

The diagnostic key for OCD is to locate the obsessive thought that initially raises anxiety distress and the compulsive thought (it's usually a thought, but not always) that provides the temporary relief. This pattern of anxious arousal followed by temporary relief creates an ongoing, self-reinforcing cycle. It exists independently of any past or present conflict or unresolved issue. That's why traditional talk-therapy approaches to OCD provide such limited help. Instead, effective help for OCD must target the factors that maintain the symptoms, not discussions of their origins or analysis of their content.

Clients with OCD can present as panicky, depressed, and agoraphobic, as well as with a wide range of personality problems and relationship issues. The obsessive and compulsive elements of OCD can have almost any content, since it's this functional relationship—that obsessions raise anxieties, while compulsions lower them—that defines the disorder. If the obsession has depressive content, the client can be incorrectly diagnosed as depressed. Thus, OCD can masquerade as a wide variety of issues or problems.

One such OCD client referred as extremely depressed was really obsessed with the idea that he'd lost the girl of his dreams and would never find someone as good. His compulsions centered on trying to figure out ways to win her back. Another client, who refused to venture several blocks from her home, was diagnosed as agoraphobic, but her fears weren't about the onset of a panic attack, as with true agoraphobia; rather, she feared the obsessive thought that she might rip off her clothing and be taken to a mental hospital. Yet another client feared dogs, which seemed like a specific phobia, but it turned out that her frightening obsessive thought concerned the possibility of being bitten and contracting rabies without her knowledge. After contact with dogs, she went through an elaborate (but secret) checking ritual for bites.

It's not uncommon for people with OCD to become obsessed with their sexual orientation. We've seen straight people become terrified that they might be gay, and gay people become obsessed with the thought that they might be straight. They differ markedly from individuals who are genuinely exploring their sexuality in that clients with OCD generally report a terrifying thought—What if I'm gay (or straight)?—followed by compulsive checking to see if, indeed, they are. This ongoing checking, usually accompanied by extreme anxiety, could include searching the Internet for confirming or disconfirming information, compulsive exposure to both male and female erotica in an effort to determine which gender provides the greater arousal, and an urgent need to know for sure.

Other people with obsessive pathological doubt can seem to have difficult personality problems or relationship issues. They may be utterly dependent on constant reassurance or present with conflicts about having children or making a job change. Some may even present with all-consuming philosophical, existential, or religious concerns. All these presenting issues, however, involve the need for certainty in a world that provides little. In fact, intolerance of uncertainty is a central feature of OCD.

Treatment Approaches

Until 2000, compulsions were defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM) as irresistible "behaviors." We now understand, however, that all compulsions—behavioral and cognitive—are defined by their ability to provide temporary relief from anxious distress, which has led to advances in the treatment of OCD. Although OCD isn't listed as an anxiety disorder in DSM-5, general principles about what maintains OCD and how best to treat it remain unchanged by this nosological decision. As with all anxiety disorders, avoidance of anxiety is both what maintains and strengthens it, and overcoming the disorder means counterintuitively moving clients toward experiences that increase their distress. In other words, exposure—if done the right way—is the active therapeutic ingredient.

The understanding that compulsions are the engines that drive obsessions has led to the development of ERP as a special type of exposure work for OCD. Simply put, clients are deliberately exposed to triggers that set off obsessive thoughts—along with the strong urge to avoid and the increase in anxiety—while refraining from engaging in any compulsions (behavioral or mental) used for dealing with those thoughts. During this time, the clients are helped in coping with their anxiety by focusing on the following five steps.

  1. Expect to feel triggered because of prior sensitization.
  2. Label the thought and anxious arousal as OCD, since labeling is the first step toward disabling.
  3. Surrender the struggle and allow the distress to remain without trying to push it away through compulsions, since that which we resist tends to persist.
  4. Actively allow the thoughts and feelings to remain. This is more than "putting up with" them: it's welcoming them with open arms.
  5. Tolerate the uncertainty that you might be wrong in each of the previous steps.

Going through these steps stops the reinforcing cycle and leads to extinction (either inhibitory learning or habituation), allowing new neurological pathways to form so that distressing thoughts—unreinforced by the effort to defeat or respond to them—begin to feel less important. Over time, the obsessional thoughts decrease in frequency and intensity. Thoughts not dreaded, avoided, or resisted lose their power to demand the compulsive response that maintains and reinforces them.

An example of ERP for OCD with behavioral compulsions would be deliberately to touch "contaminated" doorknobs in public places, and then refrain from any washing. Another example—this time for a "checker"—might be to write down the sentence "Perhaps I sent an abusive email without realizing it" and then refrain from checking email or calling anyone for reassurance for the remainder of the day. An example of ERP for scrupulous mental compulsions would be deliberately to imagine committing a sin, and then refrain from mental prayers or self-talk undoing the thoughts. Another variation would be repeatedly to imagine transgressing while acknowledging the possibility of never being forgiven by God.

A major challenge for the therapist is to watch for and eliminate subtle and sneaky compulsions that can be substituted for more obvious ones. So, for example, the person who touches a "contaminated" doorknob and doesn't wash might imagine how good he's going to feel when—after the session—he washes the contamination away. Or a person who's refraining from checking to see if he's hit someone while driving might run a mental memory check of the whole trip "to make sure" there's no need to go and check in person. These delayed, substituted, and covert compulsions need to be identified and addressed as part of the treatment.

Obsessive thoughts feel powerful and generate feelings of anxiety, guilt, and disgust. People with OCD often imbue them with special powers, including messages about self-worth or omens of the future. The therapeutic task is to help the client understand that—despite the profoundly different way they feel—obsessive thoughts are just thoughts. They're not messages, predictors, or statements about self-worth, and most importantly, they're not impulses to perform the compulsive action.

At times, this task can be uncomfortable and difficult for therapists. The erroneous but commonly held assumption that a frightening intrusive thought is linked to an impulse can raise serious doubts about the safety of clients with violent and sexually charged mental images. In this case, it's helpful to realize that thoughts get stuck by virtue of how much energy is expended to get rid of them, so they're actually the opposite of an impulse. People with obsessive thoughts of causing harm value gentleness and abhor violence, so they fight most fiercely against—inadvertently reinforcing—those thoughts.

Another treatment challenge involves the therapist's desire to provide empathic support and appropriate reassurance, or to problem-solve with the patient. While this may be helpful for some, in many people with OCD, the therapist can end up unintentionally joining the client's obsessive compulsive cycle in a mutually reinforcing dance called co-compulsing.

OCD is a chronic intermittent disorder that waxes and wanes over the course of a lifetime. It varies with mood, stress, and fatigue. Appropriate medications can render obsessions and compulsions less intense, frequent, and overwhelming, but jolts from the OCD mind can reemerge occasionally, even in those who are leading satisfying and psychologically flexible lives. An enduring recovery is one in which clients have fundamentally changed their relationship with their minds, in such a way that they can tolerate uncertainty, ride out apparent demands of an internal OCD bully, and take a nonurgent, nonjudgmental, disentangled stance when symptoms arise. Recovery, in the words of Claire Weekes, author of Hope and Help for Your Nerves, is when symptoms no longer matter.

Martin Seif, PhD, ABPP, cofounded the Anxiety and Depression Association of America. He's associate director of the Anxiety and Phobia Treatment Center at White Plains Hospital and a faculty member of New York Presbyterian Hospital / Cornell Medical School. He maintains a private practice and is the coauthor of What Every Therapist Needs to Know about Anxiety Disorders: Key Concepts, Insights, and Interventions. Contact: MartinNSeif@gmail.com

Sally Winston, PsyD, cofounded and codirects the Anxiety and Stress Disorders Institute of Maryland. She's the inaugural recipient of the national Jerilyn Ross Award of the Anxiety and Depression Association of America for her advocacy efforts on behalf of people with anxiety disorders. She's the coauthor of What Every Therapist Needs to Know about Anxiety Disorders: Key Concepts, Insights, and Interventions. Contact: Sallywins@aol.com