Managing Obsessive-Compulsive Disorder
Obsessions are very intrusive and distressing thoughts or images that go well beyond the content of worries. Compulsions are repetitive actions or thoughts that are done to reduce distress, to ameliorate doubt and/or to "prevent" something bad from happening.
Who among us has not had disturbing (e.g., obscene, violent, blasphemous, racist, mean-spirited, rude, etc.) thoughts pass through our minds? For most of us, these are dismissed with a shudder as mere "brain noise." For some of us, these are the catalysts for profound doubts and alarm.
For example, many new parents may experience obsessional thoughts of unwittingly harming their infants. Such thoughts often provoke intensely irrational alarm and shame: "Do I not want this child? Is thinking it the first step toward doing it? If I tell anyone about this, they'll lock me up!"
Prevalence of Obsessive-Compulsive Disorder = 2-3% Of these, many are primarily obsessional (i.e., no overt compulsions, but there may be lots of cognitive compulsions) who are tormented by disturbing thoughts and inner efforts to control or neutralize them. Reassurance-seeking and efforts to neutralize thoughts may become compulsions that are frequently irresistible.
Obsessive thoughts may focus on the most inappropriate, vile, offensive, ridiculous, dangerous or shameful thing you can imagine. Such content, coupled with the knee-jerk effort to suppress or neutralize the thought, is exactly what makes it "stick." The "jolt" your body feels when you have the thought makes the thought seem very important. Fearful thoughts like "why take the chance?" often drive compulsions to momentarily allay doubt.
Many people assume that OCD is primarily defined by overt washing, checking or ordering. Hence, they may believe that the OCD diagnosis does not apply to them or to their loved one. But most of the OCD cases we treat are not of this stereotypic kind. The article below provides an excellent review of seven seemingly "atypical" but actually fairly common types of OCD: Hyperawareness or sensorimotor OCD, emotional contamination OCD, pedophilia OCD, perfectionism OCD, scrupulosity OCD, homosexuality OCD, and harm OCD.
Common obsessive thoughts: (Also, see Unwanted, Intrusive Thoughts page.)
What if I hurt my baby?
What if I'm gay? (in a heterosexual person, or vice versa)
What if I lose control of myself and say something crazy or awful?
What if I lose control of myself and do something crazy or awful? (e.g., suddenly turning the steering wheel while in traffic, jumping from a moving car, jumping from a high place, cutting off all my hair, fondling someone, having sex with an animal, running naked into the yard, doing something obscene or blasphemous in church).
What if I carelessly contaminate myself/my family with germs/disease?
What if I carelessly leave doors unlocked, the stove on, etc.?
What if I can't trust what I remember, what I said, or the contents of consciousness? What if nothing's real?
Checking, repeating, washing or disinfecting, praying, counting, ordering, hoarding, reassurance-seeking, touching, neutralizing thoughts, replaying memories, perfectionism about errors, doing something until it feels "just right." (Notice that "compulsions" are not the same as impulse disorders like "compulsive gambling" or "compulsive spending.")
Like with worries, the consuming desire to get rid of obsessive thoughts is not a solution. It is the major contributor to the problem.
Those plagued by obsessions doubt their self-control of their own behavior. Yet, such individuals' profound alarm and guilt about their disturbing thoughts suggest that their brain's orbital frontal cortex is successfully doing its job: actively inhibiting untoward or dangerous actions, no matter what the thoughts. OCD is a disorder of overcontrol, not undercontrol. If you have manifestations of OCD and have never acted on such thoughts but are severely distressed by them, the inhibitory activity of your brain is entirely contrary to your fears. Check with a professional familiar with OCD.
Like with worry, many of the same cognitive errors rule:
Thoughts are over-valued.
("If I keep thinking this, it must be really important.")
Doubt is translated into actual danger.
("Thinking it is dangerously close to doing it. If I keep thinking it, I must be getting closer to doing it.")
Thought content must be controlled.
("I've got to use will power!")
Total certainty is not only possible but imperative.
("How can I be absolutely sure I won't….")
Need to avoid culpability.
("If I'm careful enough, I can't be held responsible for bad things.")
Magical power to keep things from happening.
("If I can control this bad thought, my loved ones will be safe.")
Wish to erase all risk.
("If I'm careful enough, I can control the risk.")
Thus, effective treatment often begins with cognitive therapy and education tailored to address such errors in thinking. A primary focus of cognitive therapy is to increase tolerance for uncertainty and a willingness to "take risks" rather than grasping at momentary (but futile) feelings of certainty that perpetuate the cycle. CBT also emphasizes that, no matter how compelling, the content of obsessive intrusions is irrelevant. In some individuals, such an understanding may be enough. However, most individuals will need to use exposure (i.e., repetitive, voluntary immersion in the obsessive thought they ordinarily try to avoid or neutralize) in order to recover. For compulsions, special effort will be directed toward response prevention (i.e., blocking the automatic connection between the anxiety-arousing obsession and the anxiety-relieving behavior or thought). They will be encouraged to "lean into" uncertainty and discomfort whenever possible. Over time and across repetitions, they become more inured to obsessional content most of the time; but, they also become more willing to accept the jolt of uncertainty and discomfort when it does occur, without trying to get rid of it and, thus, getting entangled.
Examples of self-conducted exposure, preferably guided by a therapist familiar with OCD:
"Scheduled Obsessing": Schedule several times per day when you give your full attention to your obsession and the distress that accompanies the thought. Try to postpone other intrusions of the obsession until your next scheduled time to give it your full attention. Aim not to do or think anything to lessen your distress until a set time on the clock.
"Loop Tape": Your therapist can help you write a vivid transcript of your obsession that you record. You can then listen to this for regular exposure sessions to the point of habituation, (i.e., until no anxiety is aroused and you mostly feel bored listening to your own once-scary obsession).
Standard Exposure: If you fear "satanic" thoughts, you might watch The Exorcist repetitively to the point of boredom. If you fear harming children, you might research the Andrea Yates case until it no longer raises your anxiety. If you fear sexual thoughts, you might repeatedly write every "dirty" word and act you can imagine. If you fear "germs" or contamination, you might deliberately touch "dirty" things. An OCD therapist can help you tailor exposure to your particular obsessions.
Change the status quo of an obsession: Don't try to make it go away, but change the obsession in some manner. For example, sing the content of your blasphemous thought. Write down everything that you can think of in five minutes related to a sexually charged obsessive thought. Make all AIDS-related obsessive thoughts "blue" in your mind (e.g., color them blue and envision the word "blue" amidst such thoughts) and remind yourself that all such "blue" thoughts are obsessions. Turn your obsessive image of a reprehensible act into an absurd slapstick comedy that "plays" in your mind. There are myriad variations of exposure that can be adapted for most forms of OCD.
Medications can be very useful and can sometimes be imperative for OCD:
Anafranil (clomipramine) was the first "antidepressant" that also showed anti-OCD effects, too. SSRI's (e.g., Prozac, Paxil, Zoloft, Celexa, Lexapro and Luvox) and other "antidepressants" (e.g., Effexor) are the most commonly used, are generally best tolerated, and are well-studied. Higher range dosing for longer periods is the norm. Combinations of medications may augment your response. There can be remarkable individual differences in response and side effects across the various medications. Having no response or uncomfortable side effects to one drug does not predict your potential response to another drug. Consult with someone who is an expert in the psychopharmacology of OCD and be patient.
Further Reading: Obsessive-Compulsive Disorder
ASDI's Dr. Sally Winston has co-authored (with Marty Seif, Ph.D.) an article entitled, "Breaking the Cycle: OCD Treatment that Works" in the Psychotherapy Networker.
Link: Psychotherapy Networker
and a book, entitled: Overcoming Unwanted Intrusive Thoughts: A CBT-Based Guide to Getting Over Frightening, Obsessive, or Disturbing Thoughts. New Harbinger, 2017.
Expert Opinions from International OCD Foundation: http://iocdf.org/expert-opinions/
Grayson, J. Freedom from Obsessive-Compulsive Disorder: A Personalized Recovery Program for Living with Uncertainty. Updated Edition. Berkeley Trade, 2014.