Obsessive-Compulsive Disorder (OCD) is a surprisingly common and potentially crippling anxiety disorder. Only 25 to 30 years ago, it was believed to be a rare psychiatric illness that affected only a small fraction of the population. Currently, however, owing partly to a growing awareness of effective therapies for it, OCD is now known to impact millions of Americans at any given time.
Left untreated, OCD can dramatically straightjacket people's lives by encumbering them with relentless, irrational, horrific, intrusive thoughts and images (obsessions) and very time consuming, repetitive or elaborate, maladaptive behaviors (compulsions). Yet, as debilitating as it can be, OCD responds very well to nonmedical, behavioral therapy (e.g., CBT). Indeed, for most people, CBT should be considered as the first-line treatment for OCD. In fact, neuroimaging studies have shown that CBT for OCD changes brain activity in the same way as medication but is more effective, has no risk of drug side-effects, and has a much lower relapse rate.
The foundation of CBT for OCD involves a method called exposure and response (or ritual) prevention (ERP). When properly done by a skilled therapist, provided the OCD sufferer is highly motivated, as many as 80 percent of people can be significantly helped. Compare this to medical treatment that has only a 50 % improvement rate and carries a much higher risk of relapse in addition to various side-effects.
In essence, as I tell my clients, ERP is simple but not easy. It's not complicated but requires a tremendous amount of psychological effort. That's why motivation for change is one of the best predictors of success because doing ERP requires real grit.
At its core, OCD behaviors are counterproductive efforts to increase or maintain a sense of safety when people feel threatened, at risk, or in danger. But, ironically, the safety seeking actions only lead to worsening anxiety (because of what is called negative reinforcement; not to be confused with punishment). In simplest terms, the maladaptive safety seeking behaviors typical of OCD are avoidance, escape, and reassurance seeking.
Avoidance: Essentially efforts aimed at not facing or not experiencing an anxiety triggering stimulus (i.e, a thing, event, or situation that evokes anxiety).
Escape: Basically doing a ritual. This is an action or behavior that is done in response to anxiety in an effort to neutralize it. These can be overt, or observable, such as washing, checking, cleaning, arranging, repeating, or moving a certain way. Rituals can also be covert, or private, such as thinking specific thoughts or changing certain thoughts or images into less threatening ones.
Reassurance seeking: Repeatedly asking questions in an effort to have others provide comfort by confirming that nothing bad happened or everything is okay. In some case, this can involve seeking reassurance from internet searches and social media, phone calls to hospitals, or the police.
As stated above, these safety seeking, OCD behaviors paradoxically strengthen anxiety and lead people to feel even more worried and insecure. Indeed, OCD is often referred to as "the doubting disease" because at its root are deep feelings of doubting some important aspect of safety (i.e., being at risk or in danger). Hence, the OCD sufferer is "compelled" to reduce doubt and increase feelings that things are safe but only worsens the illness by engaging in maladaptive rituals (irrational or excessive safety seeking) that negatively reinforce it.
ERP for OCD involves sufferers, and significant others, learning how not to enable OCD by (often inadvertently) feeding the illness with its three primary fuels (i.e., avoidance, escape, and reassurance seeking).
The only way to beat OCD is by experiencing and psychologically processing triggered anxiety (exposure) until it resolves on its own without trying to neutralize it with any safety seeking action (response or ritual prevention). As one of my OCD clients cleverly put it, "Better sane than safe!" As for what family members can do, the best way to help a loved one is with gentle, "tough love" that requires not helping with any OCD behaviors especially, in many cases, not providing reassurance.
All OCD suffers engage in some degree of anxiety strengthening, avoidance, escape and/or reassurance seeking. Nevertheless, it is important to keep in mind the all people are unique and thus everyone will require a highly individualistic ERP treatment. Some do well with a gradual approach that usually involves slowly ascending a hierarchy of anxiety triggering situations like climbing a ladder rung by rung. Others do better with a much more aggressive, head on ERP that confronts some of the most anxiety provoking challenges right out of the gate.
In either case, what is most crucial is that the OCD sufferer does not do any safety seeking rituals (i.e., escape or seek reassurance) but instead waits until his or her anxiety levels decrease significantly while staying in the triggering situation. In some cases the anxiety subsides rather quickly - within a matter of minutes - while in other cases it can persist much longer. As unpleasant as it is, the anxiety people feel when doing ERP is necessary for progress and improvement to occur. It should be interpreted as the brain trying to rebalance its chemistry and normalize its activity. So, as I often tell my OCD clients, "The pain [of anxiety] that you feel is your brain trying to heal."
If person with OCD simply, but not easily, stops avoiding anxiety triggers, refuses to escape from irrational anxiety by neutralizing it with a ritual, and resists the urge to seek reassurance, he or she will cut off the fuel that powers the OCD engine. Eventually, like a car that runs out of gas, to a greater or lesser extent, the OCD will stop, too.
Remember: Think well, act well, feel well, be well!
Copyright by Clifford N. Lazarus, Ph.D.