Norman Toth/
Source: Norman Toth/

…including psychotherapists. And not to throw the well-intentioned baby out with the bath water, but not recognizing the basics of treating Obsessive-Compulsive Disorder (OCD) means clients continue to spin their wheels on the unremitting anxiety treadmill.

Public enemy #1: focusing too much attention on the fear-based obsessive thoughts. For example, “I must wash my hands of all germs so I don’t infect my family with an incurable disease,” and the elimination of the subsequent rituals (compulsive hand washing, avoiding dirt) when this is not of primary clinical importance.

Sound counterintuitive?

I know. The first time I heard this I had the same reaction. Read on for more common pitfalls in the treatment of OCD.

What is Obsessive-Compulsive Disorder?

Obsessive-compulsive disorder (OCD) is defined by recurrent intrusive thoughts or images (obsessions) that create significant distress and compel people to perform repetitive behaviors or mental rituals (compulsions) in an attempt to reduce the anxiety.

OCD causes substantial disability due to its severe and chronic course. As with most complex neuropsychiatric disorders, the causes underlying OCD are not well understood, although genetic contribution is estimated in the range of 40 percent to 50 percent

In the U.S., approximately 3.3 million people have OCD, or roughly 2.3 percent of the adult population, and 1 in 100 children.

Studies of OCD have found the cause to be damage to a specific part of the brain called the basal ganglia. Medications such as clomipramine, or other SSRIs are often prescribed, with 40 to 60 percent of people responding to pharmacological treatment.

In addition to medication, Cognitive-behavioral therapy (CBT), including exposure response prevention (ERP), is typically used to treat OCD.

Treatment Essentials for Obsessive-Compulsive Disorder

Anxiety is a biologically based indicator of danger, an emotion that signals something is wrong and immediate attention is warranted to avert a problem or catastrophe. With OCD, the brain misfires danger signals, but reacts as if a true danger was imminent. Common misconceptions about overcoming OCD include the following areas of focus:

  • Over-attention to the content of the thoughts, and under-attention to the process of anxiety
  • Seeking reassurance that things will be okay, including fact checking and avoidance of feared stimuli
  • Dismissing the importance of completing daily homework assignments

The following strategies can help:

1. Forget the ‘why?’ behind the bizarre, irrational obsessive thoughts, for they are not necessarily indicative of pathology, reality or childhood trauma. For example, Steve suddenly develops an obsession that he will become a child molester if permitted to be in the same room as a child. However, the impulse is usually not the root of the problem. In fact, the fear may not be based on any transgression or subconscious desire, at all. This non-linear causal connection makes understanding the brain of an individual with OCD all the more vexing. As humans, we naturally want to know why something happens, but satisfying curiosity can derail action.

Everybody experiences bizarre, unwanted thoughts, but people with OCD attribute meaning to these thoughts and their subsequent anxious reactions. Complicating matters are the physical signs that accompany anxiety when the amygdala (area of the brain responsible for the fear response) floods the brain with danger signals to prepare for fight or flight. Symptoms include rapid heart rate, shallow breathing, tightening of the chest, and blurred vision, etc. As scary as this experience is, remembering that feelings and thoughts are constructs of the human mind, and not facts can be helpful.

2. Expect to worry. Life is rife with problems, and no amount of wishful thinking, seeking a loved one’s reassurance, or trying to control the environment will ease anxieties. In fact, these tactics may exacerbate symptoms. Accepting that stress is a part of life enables sufferers to be more tolerant of unwelcome events, including the discomfort associated with not performing certain rituals.

3. Take a social supports inventory. Well-intentioned family and friends often rearrange social gatherings, vacations, and daily activities to appease the person with OCD. When individuals go out of their way to control environmental conditions for perceived danger, they inadvertently reinforce the very behavior they are trying to help eliminate. For example, Denise is afraid of dogs to the point that she won’t go shopping. If her partner John combs every aisle in Whole Foods for canines until the coast is clear, he enables Denise’s avoidance by providing proof that dogs are dangerous and should be vetted before going out in public.

4. Complete daily homework. Anxiety loathes problem-solving and stepping outside its comfort zone. However, combating intrusive, exhausting, and debilitating thoughts and rituals entails executing a plan of action. Every. Single. Day.

Putting nervous energy toward a course of action, including ERP: exposure and response prevention (gradually facing fears and then refraining from ritualizing), means less time spent on procrastination and rumination. Anxiety loves drama, and rigid, inflexible and concrete thought patterns. The antidote is a calm, flexible and open mindset. Remember, with anxiety, it’s the reaction that is the problem, not the thought itself. This article provides information on deep-breathing, relaxation and mindfulness, while in-depth details about Cognitive-Behavioral Therapy, are found here.

The bottom line about OCD (or any other anxiety-related disorder), is at its core, anxiety is over-reacting to worries, and under-reacting to problem-solving. The good news is anxiety is highly treatable, and help is available.

“It isn’t what happens to us that causes us to suffer; it’s what we say to ourselves about what happens.” —Pema Chodron


Copyright 2016 Linda Esposito, LCSW

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