Understanding OCD

It might surprise you to learn that Obsessive Compulsive Disorder is not always about cleaning or excessive orderliness....

What is OCD?

OCD is a neurologically based disorder that leads otherwise healthy individuals to worry about specific concerns in an intensely, exaggerated manner. The concerns of the individual with OCD may be realistic on some level but, so out of proportion  to reality as to be well beyond what is practical or constructive.  An individual with OCD suffers obsessions, which are repetitive intrusive negative thoughts or worries as well as compulsions, which are ritualistic actions or behaviors intended to reduce these worries.  OCD effects both children and adults and most individuals with OCD struggle to keep their disorder secret while trying to maintain a relatively normal life.  

What makes OCD so difficult to manage, is that it typically involves both an intense preoccupation with a specific fear or group of related worries as well as strong anxiety about abandoning the ritualistic compulsions one has developed to try and keep those worries at bay.  

If OCD Isn't Just About Cleaning...What is it About? 

It may surprise you to learn that OCD is not merely a fear of germs and an overriding attention to orderliness.  Other worries related to OCD may involve issues of health and safety, fears of embarrassment, fears of being less than perfect in school or at work, and fears of causing harm to others.  

In truth, OCD tends to attach itself to whatever concerns might be important to a person at a particular time in his or her life.  Therefore, the focus of an individual's obsessions and compulsions are likely to change over the course of time.  A very young child with OCD might be highly focused on maintaining the order of his or her toys or other belongings, as control over these items may be paramount in a child's early thinking.  An older child or teenager may become obsessive about their school work or about aspects of their personal appearance.  Adults with OCD tend to focus on issues of health and safety, as the realities of  taking responsibility for one's self and others become highlighted with maturity.  At any point in life, awareness about the relationship between germs and illness or thoughts about the fragility of life may give rise to an individual's exaggerated OCD focus on cleanliness or even generate intense fears that they might do something awful to cause serious harm to others.

Why does OCD behavior often appear so odd?

OCD compulsions are performed in response to an idividual's obsessive worries.  They're usually carried out ritualistically, meaning repeatedly and in the same fashion, in order to reduce a person's obsessive fears.

Some compulsions are relatively easy to explain, such as repetitive hand washing to reduce obsessions about germs or the ritualistic checking of doors and windows to insure family safety.  Other compulsions are not so easily understood, like the repetition of a “lucky” word or phrase, the tapping of a table or wall, or  repeatedly entering or leaving a room or climbing a staircase, over and over again.  Sometimes people with OCD feel that they must complete their compulsion "just right" in order to calm their anxiety.  These seemingly odd or random compulsions may have become associated with the reduction of an individual’s anxiety incidentally. That is, they , they may get linked to the reduction of an individual's OCD worries by coincidences in thinking (e.g., "If I say this word, tap this wall, or enter the room "just right" maybe the bad thing I'm worried about won't happen!"). Having  been used by the individual to reduce their anxiety in the past, these seemingly random and sometimes very odd behavioral tics get repeated as long as they continue to ward off an individual's stress. 

A Surprising Hallmark of OCD

One of the defining markers of OCD, in contrast to more insidious psychiatric conditions, is that individuals with OCD usually know that the beliefs they hold are irrational and that the compulsions or rituals they are performing are either silly or unnecessary.  Strangely, though, that knowledge alone doesn’t mean that they can stop their OCD worrying or ritualistic behavior.  How a person with OCD can acknowledge the irrationality of his or her obsessions, on the one hand, and yet feel driven to obey his or her obsessional thinking, on the other, is one of the ongoing frustrations of OCD for both sufferers of this disorder and for the people around them.  

How OCD Develops

 It turns out, obsessions are only as strong as we make them out to be.  Our brain does not really “think” for itself…it processes information according to what we feed it.  If we ignore an alarm signal from the environment, it fails to gain any traction in our brain and we ultimately deem it unimportant.  However, if we attend to an alarm signal—over and over again as with an obsession—it assumes an even greater place within the hierarchy of concerns that exist within our brains.  To put it simply, the more we worry about something (e.g., germs), the greater our brain believes that particular worry is important.  And, people with OCD worry about their obsessions a lot!  

With OCD, the problem is worrying repeatedly and intensely about things that, in reality, pose no real threat.  It doesn’t matter if its truly unimportant…our brains think these worries should matter to us based on the number of times we have “thought” about it and the intensity with which we think about it.  For an individual with OCD,  either worrying about an OCD fear and performing a compulsive ritual or going back and forth and debating whether to perform that ritual amounts to the same thing...it still causes the brain to focus on that OCD thought.  That focus triggers an ongoing cycle of continued attention and additional worry even when the person with OCD recognizes how absurd their worry is in the first place!  

Problems with Traditional Talk Therapy for OCD

Traditionally, therapists have treated persons with OCD through talk therapy designed to help individuals gain insight into the subconscious motivations beneath their obsessive behavior.  More progressive therapists may try to engage OCD sufferers in rational arguments designed to dispute the reasonableness of OCD behavior.  And, family members have typically tried to alleviate the worries of OCD sufferers through constant offerings of reassurance and even by forcibly trying to “block” loved ones from engaging in their obsession.  However,  the problem with each of these approaches is that they only add fuel to obsessional thinking by increasing the brain's attention to the OCD thought.

Effective Treatment for OCD with Cognitive-Behavioral Therapy and Exposure

Since “thinking” about an obsessive worry actually fuels its intensity, even in the context of trying to convince one’s self of it’s irrationality, treatment of OCD, therefore, depends not on an exhaustive rehashing over and over again of one's fears and preoccupations, but, on an abrupt refocusing away from one's obsessive worries and a disengagement from compulsive rituals.  

Cognitive-Behavior Therapy (CBT) involves a number of components that make it highly effective in the treatment of Obsessive-Compulsive Disorder.  In fact, research has found CBT to be the most effective form of treatment for individuals suffering with OCD problems.  CBT is highly goal oriented and focused and brings together the power of the following important elements in the effective treatment of OCD

• Psychoeducation--to help clients better understand and come to terms with their OCD patterns
• Coping Skills Training--to help clients reduce the intensity of anxiety produced by their worried thoughts and manage their fears about resisting their own compulsions
• Cognitive Therapy--to help clients mentally turn away from obsessive worries and help them change thinking patterns that give rise to OCD symptoms
• Exposure Therapy--to help clients confront and learn to cope with the particular situations and thoughts that "trigger" their OCD worries and behaviors
• Family Education--to help the family members of individuals with OCD learn how to best assist in their loved one's recovery from obsessive-compulsive disorder

Exposure Therapy (ERP) and its Importance in the Treatment of OCD

Exposure Therapy is an especially important component in the cognitive-behavioral treatment of OCD.  It involves training clients to use healthy, functional coping skills (e.g., relaxation, calming self-talk) to deal with obsessive anxiety in place of performing disruptive rituals.  During exposure exercises, individuals with OCD are gradually exposed to the situations that provoke their anxiety symptoms and they are guided in using the functional coping skills they've learned to manage increasingly longer or more intense experiences in these previously feared situations.  

Exposure Therapy  is more commonly referred to as ERP because it involves both exposure (to anxiety provoking situations) and response-prevention (prevention of the outright avoidance of the situation or the performance of rituals).  An example of exposure therapy might be having an individual with fears about contamination actually practice touching a variety of greasy, grimy objects without stopping to wash their hands or use gloves.

While participation in exposure exercises is highly effective in reducing OCD symptoms, individuals with OCD should never be forced or bullied into confronting their feared situations.  Exposure exercises are mainly effective when they are planned and designed by clients and their therapists collaboratively.  With good planning and a trusting relationship between client and therapist, exposure therapy combined with other aspects of CBT therapy can be highly effective in helping clients reduce their OCD fears, overcome their urges to perform compulsive rituals, and live more satisfying lives.

                                              --M. William Futtersak, Ph.D., Clinical Psychologist