Obsessive-Compulsive Disorder (OCD) is a complex and often debilitating mental health condition that affects millions of people worldwide. Characterized by persistent, intrusive thoughts, images, and sensations (obsessions) and repetitive behaviors or mental acts (compulsions), OCD can severely impact daily life and well-being. Unfortunately, popular media often portrays this disorder in an exaggerated, stereotypical fashion leading to a host of misinformation about what OCD is and what it isn’t. While some of what we see in films such as As Good as It Gets and Silver Linings Playbook, is accurate to a certain degree (i.e. repetitive, compulsive behaviors resulting psychosocial impairment), the dramatizations rarely depict, at least in any truly authentic way, the level of internal distress this disorder causes the sufferer nor does it demonstrate the wide variety of themes that can be manifested by OCD.
What is OCD?
OCD is an anxiety disorder marked by the presence of obsessions and compulsions. Obsessions are unwanted, intrusive thoughts, images, or urges that cause significant anxiety, distress or even disgust. To alleviate this discomfort, individuals engage in compulsions—repetitive behaviors or mental acts performed according to rigid and sometimes arbitrary rules in response to the obsessions. While compulsions can bring temporary relief to the distress an individual experiences, they reinforce the fear overtime which increases the sufferer’s need to engage in more and more compulsive behavior. This cycle of obsession and compulsion creates a trap that can be difficult to escape without professional help. To make matters even worse, OCD seems to latch on to real events, circumstances and an individual’s values, making it very difficult to differentiate between actual concerns and “imaginary” ones.
Most of us, however, have obsessive thoughts and some of us even engage in compulsive behaviors. ALL of us struggle with uncertainty to some degree or another, but this does not mean we’re all “a little OCD”. To qualify for the diagnosis of obsessive-compulsive disorder, an individual must experience these obsessions and compulsions as intrusive and unwanted (i.e. they experience no enjoyment when rearranging objects in the room) AND it must lead to significant impairment and distress. At least an hour of a person’s time each day must be “hijacked” by these unwanted thoughts and behaviors in order to be diagnosed with this disorder.
OCD Themes: It's Not Just about Germs
Many people think of OCD as involving a fixation on neatness or cleanliness but in truth, OCD can present in many forms. It is not uncommon for individuals to experience more than one OCD theme at a time, and some specific obsessions may involve multiple themes.
Harm OCD
This OCD theme involves fears of causing harm to oneself or others, often leading to excessive checking or reassurance-seeking. Examples of harm-themed OCD include having repetitive thoughts or images of cutting oneself with a knife, stabbing others on impulse when around sharp objects, running over someone with their car (often referred to as “hit and run OCD”), and the like. This theme, like many others, often involves an overestimation of responsibility.
Contamination OCD
This OCD theme centers around fears of dirt, germs, chemicals/toxins (including food-borne pathogens), and bodily fluids resulting in compulsive washing or avoidance behaviors. The concerns related to these contaminants can either involve negative consequences to the self (i.e. getting terminal cancer from the toxins in cookware) or to others (i.e. causing a family member to contract a deadly disease from bacteria in the ice maker). For others with contamination-theme OCD, the concerns are mostly disgust related and do not involve fears about adverse consequences to one’s health.
Sexual Orientation OCD
This subtype of OCD is characterized by obsessive doubts about one's sexual orientation and often leads to checking compulsions (i.e. checking for arousal or other physiological sensations, checking memories for evidence of attraction, reviewing social interactions or replaying conversations) and reassurance-seeking.
Pedophilia/Sexual Taboo OCD
Because of the sensitive and taboo nature of this OCD theme, sufferers are often reluctant to share with their providers some of the thought content of these obsessions and experience significant shame. This theme involves variations based on the age of the sufferer and might include intrusive thoughts about inappropriate sexual behaviors with children (in adult patients) or obsessions about being romantically/sexually attracted to a family member (in pediatric patients), causing significant distress despite a lack of desire or intent. Compulsions are often avoidance or reassurance-seeking.
Moral/Religious Scrupulosity OCD
This OCD theme focuses on fears of moral or religious transgressions, such as not telling the complete truth, being a racist, displeasing God/religious deity, or committing an unforgivable sin. Compulsive behaviors resulting from these obsessions include avoidance, excessive confession, prayer, or other rituals.
“Just Right” OCD or Maladaptive Perfectionism
Obsessions in this subtype of OCD involve a need for things to be arranged or done in a specific way to feel "just right," often resulting in repetitive actions or mental rituals. One might also experience an excessive concern with remembering something perfectly or needing to gain or retain information. Occasionally there is magical thinking connected to the ritualized behavior, such as the belief that one's family member will die if the television remotes are not lined up perfectly on the coffee table.
Relationship OCD
Within this subtype of OCD, the sufferer experiences obsessions related to attraction to one’s partner, whether their partner is “the right one”, or whether their spouse’s flaws or shortcomings are indeed grounds for separation. For singles with this version of OCD, one can experience intrusive thoughts about being “the best friend possible” or whether they are too much a burden for others. Again, some of these concerns are quite normal to experience in relationships, but for the individual with OCD, these obsessions are extreme, cause marked distress, and lead to extensive reassurance seeking behaviors.
Existential OCD
This lesser known theme of OCD involves obsessions around unanswerable philosophical questions about one’s existence, the universe, the meaning and purpose of life, and what’s real (i.e. the “Matrix”). Sufferers may struggle with thoughts about losing their identity or personality or question whether or not they recognize a loved one, feeling dissociated from life and in a dreamlike state. Compulsions such as mental and overt checking, reassurance seeking, and rumination are common with this subtype.
Perinatal/Postpartum OCD
For expectant and new parents, this OCD subtype involves excessive fears related to inadvertent or intentional harm of the baby. Contrary to popular opinion which ascribes this subtype only to expectant or new mothers, both female and male sufferers can experience this theme of OCD. Common compulsions experienced in this manifestation of OCD include excessive research of baby equipment, avoiding laying arms across one's baby bump, avoidance of changing diapers for fear of hurting baby’s genitalia or sexually abusing the infant, and asking for reassurance.
[And, yes, there are others]
The Treatment: Exposure and Response Prevention
Exposure and Response Prevention (ERP) therapy is a cognitive-behavioral treatment designed to help individuals confront their obsessions and resist the urge to perform compulsive behaviors. The underlying principle of ERP is to expose individuals to their feared situations or thoughts in a controlled manner, while preventing their usual compulsive responses. Over time, this approach helps diminish the power of the obsessions and reduces the compulsion to engage in rituals.
The rationale for ERP therapy lies in its ability to address the fundamental mechanisms of OCD. Obsessions provoke anxiety, and compulsions are performed to reduce this anxiety. However, this avoidance strategy only reinforces the obsession-compulsion cycle. By confronting fears directly and refraining from compulsions, individuals can gradually learn that their feared outcomes are unlikely or less distressing than anticipated, which, in the context of inhibitory learning theory, is known as expectancy violation.
ERP therapy is typically structured in several stages:
1. Assessment, Psychoeducation, and Goal Setting: The therapist and client identify specific obsessions and compulsions through assessment batteries and clinical interviews, which can take several sessions to complete. The therapist provides education related to the obsession-compulsion cycle and explains the treatment strategy. The therapist and client then collaboratively set treatment goals.
2. Hierarchy Creation: The therapist and client develop a hierarchy of feared situations or thoughts, ranging from least to most distressing. This hierarchy serves as a roadmap for gradual exposure.
3. Exposure Exercises: The client is gradually exposed to these feared situations or thoughts, starting with less anxiety-provoking items on the hierarchy and working up to more challenging ones. These exposures are ideally performed in session as guided by the therapist and then repeated for homework between therapy sessions.
4. Response Prevention: During exposure exercises, the client refrains from engaging in compulsive behaviors. This helps them experience the anxiety and learn that it can decrease over time without the need for compulsions.
5. Gradual Progression: The process is repeated, with the client gradually facing more challenging fears and resisting compulsions, thereby building confidence and reducing anxiety. Relapse prevention is also discussed at this stage and many clients begin to feel confident enough to do their own ERP without as much support from the therapist.
To illustrate ERP, let’s consider a few examples:
Contamination OCD: A person with contamination OCD might fear that touching a doorknob will result in severe illness. In ERP, the individual might start by touching a doorknob without washing their hands immediately afterward. Over time, they would gradually increase their exposure to more contaminated items and situations while resisting the urge to wash their hands.
Harm OCD: An individual with harm OCD might fear unintentionally causing harm to others. In ERP, they might be exposed to scenarios where they might accidentally cause harm (e.g., handling a sharp object) while practicing not engaging in compulsive checking or reassurance-seeking behaviors.
"Just Right" OCD: For someone with "just right" OCD, where they feel the need to arrange objects in a specific way, ERP might involve gradually allowing objects to be placed in non-ideal positions and resisting the urge to adjust them.
The Bully Metaphor
To understand ERP's role in treating OCD, it can be helpful to think of OCD as a bully. This bully preys on your fears and exploits the things you care about most. Just as a bully might torment someone by targeting their vulnerabilities, OCD seizes on your deepest fears—whether they are fears of harm, contamination, moral failing, or anything else.
When confronted with these fears, OCD demands that you perform certain actions or rituals to feel safe. In essence, it uses your concerns and anxieties as leverage to control you. If you were terrified of open water for example (i.e. lakes, swimming pools, even bathtubs), you would likely avoid any situation that put you in close proximity to bodies of water. If your bully learned about this, you’d better believe it will use this knowledge to torment you. The best thing you could do in this scenario is learn to tolerate deep water. Perhaps first you learn to be okay sitting in the bathtub, then laying down under the water, then progress your way to swimming pools and lakes, until you reach the point of being able to sit at the bottom of the lake until you’re ready to emerge. This, in essence, is what ERP therapy is like: standing up to this bully by facing your fears directly and refusing to engage in the compulsive avoidance or behaviors that the bully uses to manipulate you. Over time, as you consistently resist the compulsion to perform rituals, the bully’s power diminishes. The fear becomes less overwhelming, and you regain control over your life.
The Benefits and Challenges of ERP Therapy
Benefits:
1. Evidence-Based Effectiveness: ERP is one of the most researched and effective treatments for OCD, with numerous studies demonstrating its ability to reduce symptoms and improve quality of life.
2. Skill Development: ERP helps individuals develop coping strategies and skills to manage anxiety and resist compulsions independently.
3. Long-Term Relief: By addressing the core mechanisms of OCD, ERP provides lasting relief from symptoms and reduces the likelihood of relapse.
Challenges:
1. Emotional Intensity: Exposure exercises can be emotionally challenging, requiring individuals to confront their deepest fears.
2. Commitment and Persistence: ERP requires a strong commitment to the process and persistence in facing fears and resisting compulsions.
3. Individual Variability: The effectiveness of ERP can vary based on individual differences, including the severity of OCD and the presence of comorbid conditions.
Exposure and Response Prevention therapy offers a powerful tool for managing and overcoming OCD. By directly confronting fears and refraining from compulsive behaviors, individuals can break free from the cycle of obsession and compulsion. Although ERP can be challenging, it provides a pathway to lasting relief and greater control over one's life. Understanding the nature of OCD and the rationale behind ERP therapy can empower individuals to take proactive steps towards recovery and reclaim their lives from the grip of this challenging disorder.
If you or someone you know suffers from OCD, help is available. Unlike generalized anxiety or clinical depression, which can be treated effectively by nearly any professional counselor, OCD requires a very specific type of treatment that few mental health professionals have been trained to deliver. In fact, some treatment modalities like classic cognitive behavior therapy can actually make your symptoms worse. Make sure that the counselor you choose to work with is trained and experienced in utilizing evidence-based treatments such as Exposure and Response Prevention for OCD.
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