Obsessive-Compulsive Disorder (OCD)
Most of us have had intrusive thoughts come into our minds at one time or another; thoughts we don’t necessarily want to have, and which can be unpleasant or scary.
For instance, thoughts that we could directly cause harm to a stranger (stab someone, hit someone with our car, push someone in front of an oncoming metro train, etc.), to someone we love (hit our child) or to ourselves (jump from a high place, swerve our car off a cliff or into oncoming traffic). We can have intrusive thoughts of causing harm to a loved one indirectly (them dying in a fire or from food poisoning because of our carelessness, us passing on deadly germs, etc.). Other intrusive thoughts can contain an element of taboo, such as the possibility of being sexually attracted to children or other thoughts that we ourselves would consider perverse. Other common variations of OCD are relationship OCD (questioning whether we are with the right person obsessively; or whether we or they will cheat, etc.), existential OCD (obsessing over the meaning of life), etc.
The thoughts are harmless, since a thought is just a thought, and they do come into our minds for no particular reason. The trouble comes through our interpretations of them:
“I must be a bad person for thinking this”.
“What if I really do it? I am having the thought (sometimes even the impulse), so I could do it”.
This is when the thoughts can become an obsession. By not wanting to have them, because we attribute such importance and meaning to them, we paradoxically keep them coming. Perhaps you have heard of the white bear exercise, where your only task for a set time is to not think of a white bear. You can guess what happens; all we can think about is a white bear! By trying hard not to think of an intrusive thought, as if it is really important not to do so, all we can do is think about it.
Then come the behaviors or compulsions to prevent harm and try to deal with the obsession:
Avoidance:
“I have to keep myself and others safe, and avoid placing myself in at-risk situations (those where I could do a terrible thing) and even situations where I am likely to have the thoughts” (e.g., avoid holding a sharp knife for a fear of stabbing someone).
Checking:
“I must check to make sure” (e.g., checking that I turned off the stove for a fear of setting a fire).
Seeking reassurance:
“I must seek reassurance that it isn’t true” (e.g., checking that I am not sexually aroused around children).
Mental compulsions (a thinking behavior):
Trying to “undo” the thought (e.g., if I thought of my loved one having an accident on the highway, I need to undo the thought by picturing her driving safely).
Another symptom common in OCD is the “not just right experience” (NJRE). While most of us have at least some preferences for how we like things to be (e.g., tea in our favourite mug, a way of organizing papers, etc.), deviation from this is unlikely to cause much discomfort or distress. In OCD, especially around symmetry and order, these deviations elicit a NJRE that causes enough discomfort or distress for the person to feel a strong impulse to continue to try to make it right despite the unreasonableness of the action (excessive time taken and control). NJRE are often part of contamination-based OCD as well, where one does not feel like the hand or body-washing is enough, or checking-based OCD, where one feels like they have not checked enough times.
OCD can really take over one’s life with the constant preoccupation, the anxiety, and the extra time taken by the associated behaviors. Fortunately, help is available! CBT is the most strongly recommended treatment for OCD.
Treatment
Changing the thoughts
There are many thinking patterns that maintain OCD, such as:
1) Seeking more certainty
At its core, OCD is about trying to prevent a “bad thing” from happening, harm and/or being a horrible person.
2) Thought-action fusion
Believing that because one has the thought of doing an action or of something happening, it is more likely to happen, and that if one has a “horrible thought”, they are a “horrible person”.
3) Emotional reasoning
“If I feel anxious or feel in danger, there must be a real danger”
4) Attention and reasoning biases
Focusing on signs of danger, for instance reading all about product recalls and contamination stories.
5) Thought suppression
Believing that one can control one’s thoughts and that it is very important to do so.
These thinking patterns can be corrected through psycho-education, cognitive re-structuring (reframing), and behavioural experiments to test out the predictions that follow from the thoughts. Here are some examples:
Thoughts lead to action: We can decide on a thought (e.g., “I will get up and sing”) and sit down holding the thought for five or ten minutes to see if indeed we do get up and sing; or if instead we stay sitting down, as intended.
Thoughts cause events to happen: One can buy a lottery ticket and think about winning for ten minutes each day and see what happens, or think for the same amount of time about the therapist breaking their leg, and see what happens.
I should be able to control my thoughts: For the “white bear” experiment, task yourself with not thinking of a white bear for five minutes and see what happens.
One can also run some observational experiments: Like going to a fast-food restaurant and watching how people wash their hands or not before eating with their hands.
Most importantly, though, and the focus of therapy, is that one has to be willing to accept uncertainty, with all of the awful things that it could potentially bring. Why? Because there is no alternative! OCD does not actually make you more certain. Insurance companies will not give you a rebate on your home insurance because you check your stove one hundred times per day; or a rebate on your health insurance because you wash your hands a certain number of times. In fact, research has shown that the more one checks, the more uncertain one is of whether a certain appliance is on or off, for instance. OCD only offers you the illusion of safety, at a cost that, at some point, is way too high.
Jonathan Grayson, a recognized OCD expert, has an excellent chapter entitled “Uncertainty: the core of OCD” in his book “Freedom from OCD” and also has lots of materials, videos and podcasts, on the internet that talk about uncertainty and its role in OCD.
Changing the behaviors:
Ultimately, behavior is the key! You can’t control your thoughts (remember the white bear experiment), but you can learn to find them less distressing.
Exposure and Response-Prevention (ERP):
This is the gold standard when it comes to OCD treatment. Before we get into it, here is a useful analogy:
Let’s say you are afraid of cats. What we would to help you overcome the fear is place a cat in a corner of the room and have you start in the other corner. We would take one step towards the cat together and stay there until you feel comfortable being one step closer to the cat. Once this is done, we would take another step, and then another step…until you are with the cat and unafraid. This is called “systematic desensitization”; you become desensitized to the cat.
With OCD, the cat is the intrusive thought (e.g., “I might have hit someone with my car on my way home”). The moment the thought comes into your mind, you become distressed (this would be terrible, you could have killed someone, go to jail, etc.). You then try to make the thought go away through distraction, self-talk, etc., which is the equivalent of running away from the cat. You run to the cat (have the OCD thought) and then run away (try to make it go away); desensitization cannot occur. By contrast, what we do together is bring up the intrusion and stay with it until you are ok with it; we may start with the sentence “I might have hit someone with my car without realizing it”. Then increase the intensity and stay with it again, like “I might have hit someone with my car without realizing it. The police may come to find me; I will have killed someone, go to jail, not see my kids and feel so guilty and ashamed”. Until a point is reached where you can have the thought, and while it is not pleasant, it does not elicit excessive anxiety and an urge to make it go away. This is really the difference between a “normal” reaction to such an intrusive thought (it is not pleasant to think that we may have hit someone, but we move on to other things) and an OCD reaction (excessive anxiety and urge to work hard to push the intrusion away).
“Response-Prevention” simply refers to not engaging in the behaviors that you usually do to cope with the intrusion. The “Response-Prevention” piece, in the example above, is that you are not avoiding the “I might have hit someone with my car” thought (you are staying with it), you are not distracting, you are not seeking reassurance that you did not hit someone, you are not checking your car for damage or retracing your route to make sure there is no ambulance or person hurt, you are not looking at the news to try to see if a hit and run has been reported, etc.
It is important to know that ERP is highly effective and is done at your pace. We would never ask you to do anything that poses a clear danger, that you do not see the necessity or usefulness of, or that you are not up to doing. CBT is collaborative in nature and we are there to accompany you as you face your fears.
Let us help you conquer your OCD!