The symptoms of Obsessive Compulsive Disorder can be confusing and frustrating for both the person battling OCD as well as the people around them. It is important to understand the ways that OCD presents and how to begin to fight against it.
It all starts with anxiety.
At the basis of OCD is anxiety. We need to start by breaking down anxiety and exactly what is happening in our body when we are feeling anxious. Anxiety is the body's fear response. It is designed to alert us to potential dangers and to have the body react appropriately to help protect us. Generally, this response is controlled by a small part of the brain named the amygdala which is able to react in three ways: fight, flight, or freeze. In an attempt to prepare us for danger, we will feel a variety of physical symptoms such as:
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Remember that this response is because our mind has detected a threat and puts systems into place to help you survive.
Anxiety can be formed in two ways.
All anxiety is not created the equally. When our fight, flight, or freeze response is activated, it can be activated in two ways.
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The first way that anxiety is formed is the fastest acting and often referred to as the more instinctual response. A stimulus (either something in the environment or a thought) is perceived through the senses and is directly routed to the amygdala. This process happens without you even thinking about it. For instance, if you are driving and someone pulls out in front of you, you instinctually swerve to avoid the collision. Another example is if you are walking along a path in the woods and see ahead of you a stick laying across the path, you may initially may feel alerted, perceiving it initially as a snake. The trade off for this response is that it is quick to help protect us, however, since the amygdala has no ability to be rational, we may be alerted by non-dangerous stimuli.
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The second way anxiety is formed takes a bit longer because it travels a "further route." A stimulus (something in the environment or a thought) is perceived through the senses and then it processed through the cortex / our thought process. We interpret and evaluate the stimulus and what the situation or thought means. Information is also fed from the hippocampus to the cortex from previous memories of events similar to this stimulus. From here, information is sent to the amygdala. For instance, if your boss calls you and says "come to my office" (stimulus & senses), you think "I bet I am in trouble!" (cortex), and you remember the one experience where your boss called you at your old job and were fired (hippocampus), you amygdala would react because of this possibly dangerous situation.
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Anxiety's connection with OCD
OCD is a combination of obsessive (fearful thoughts) and compulsions (attempts to reduce the anxiety). While many times we think of OCD in relation to someone washing their hands often or being organized, there are many other ways that OCD can manifest. It is also not uncommon for various obsessive thoughts to occur at the same time or to have the obsessive thoughts shift their focus over a period of time. The obsessive thoughts are intrusive, barging unwanted into the persons mind.
Common obsessions with OCD include:
- Fears of contamination - these would include dirt/ germs, household items, environmental contaminants, body waste / secretions, animals and insects.
- Fear of causing harm by accident - accidentally hitting someone while driving, leaving on a stove, oven, curling iron, etc, or leaving a window / door unlocked resulting in a robbery
- Fear of causing harm on purpose - Harming themselves or others impulsively, doing something shocking or embarrassing
- Symmetry and exactness - Distress associated with ordering and arranging items, magical thinking (if I don't do X, Y, Z then something terrible will happen to my family), thoughts about needing to protect themselves or others, and the need to "feel right"
- Sexual obsessions - unwanted sexual thoughts about family, children, violence, animals or even religious figures
- Sexual orientation obsessions - Concerns about attraction or sexual thoughts for the same sex or for the opposite sex, concerns about the meaning of their thoughts and their sexual orientation
- Pedophilia obsessions - intense fear of having sexual attraction towards children resulting in minimizing contact with children because of the feared thoughts
- Religious obsessions - concerns of blasphmy and sacrilege, excessive concerns about right and wrong, accidentally omitting someone from a prayer, performing a religious ritual incorrectly
Common compulsions with OCD include:
- Washing and cleaning - excessively washing or cleaning, avoiding contaminants
- Checking - checking locks, stoves, appliances, switches, checks about harming themselves or others, checking for catastrophes, checking for mistakes, and checking for health concerns
- Repeating - rereading parts of a book, rewriting and correcting, repeating routine activities, and repeating words or phrases
- Counting - counting steps, counting items, counting out loud, mental counting, and counting numbers of devices
- Ordering and arranging - ordering and arranging things until they are the "right way"
- Mental rituals - self-reassurance, mental counting, mental list making, saying prayers, mental "un-doing"
- Somatic compulsions - concerns about bodily feelings and sensations and what they could mean (health anxiety and sexual worries)
Meaning and Certainty: the Dangerous Duo of OCD
There are two aspects of OCD that can make the experiences of OCD even more difficult to manage. Placing meaning behind obsessional and intrusive thoughts can make the person confused and shameful of the thoughts they are having. It is important to first understand that we CANNOT control our thoughts. If you could control your thoughts, why would you ever think of sad things? We would only think about happy and wonderful things if we had the power to do that!
Intrusive thoughts are out of our control and for a long time I believed these type of thoughts meant nothing about the person. If you have consistent judgmental / critical thoughts about others does not make you a mean person. If you have obsessional thoughts that scare you about hurting other people, it does not make you a sociopath. And if you have have obsessional thoughts that scare you about awful, bad things happening does not make you a bad person. I do these think these thought do mean something but it is not always what we may interpret. OCD attacks our values and the things that are most important to us. If OCD is producing intrusive thoughts about criticizing others, it means that we really value being nice and caring to others. If OCD is producing unwanted thoughts about hurting others, it means that we would do just about anything to NOT hurt anyone else. The opposite of our unwanted, intrusive thoughts start define the true person and their values.
Secondly, the need for certainty is paramount for OCD and has been coined the "doubters disease." OCD craves certainty and will stop at no lengths to be able to try to find it. However, regardless how hard we try, there is no answer that ever seems certain enough to satisfy the OCD. These endeavors to gain certainty always come up empty, sometimes offering some temporary relief from our anxiety, only to shortly reemerge. Certainty is impossible to reach about nearly every situation and it is important to start to work to embrace that we may not have a definite answer about some of the questions that we have. We may also pull in family members into this process, asking for reassurance from them to seek for a "certain answer."
Intrusive thoughts are out of our control and for a long time I believed these type of thoughts meant nothing about the person. If you have consistent judgmental / critical thoughts about others does not make you a mean person. If you have obsessional thoughts that scare you about hurting other people, it does not make you a sociopath. And if you have have obsessional thoughts that scare you about awful, bad things happening does not make you a bad person. I do these think these thought do mean something but it is not always what we may interpret. OCD attacks our values and the things that are most important to us. If OCD is producing intrusive thoughts about criticizing others, it means that we really value being nice and caring to others. If OCD is producing unwanted thoughts about hurting others, it means that we would do just about anything to NOT hurt anyone else. The opposite of our unwanted, intrusive thoughts start define the true person and their values.
Secondly, the need for certainty is paramount for OCD and has been coined the "doubters disease." OCD craves certainty and will stop at no lengths to be able to try to find it. However, regardless how hard we try, there is no answer that ever seems certain enough to satisfy the OCD. These endeavors to gain certainty always come up empty, sometimes offering some temporary relief from our anxiety, only to shortly reemerge. Certainty is impossible to reach about nearly every situation and it is important to start to work to embrace that we may not have a definite answer about some of the questions that we have. We may also pull in family members into this process, asking for reassurance from them to seek for a "certain answer."
Treatment of OCD
The gold standard of treatment for OCD is Exposure and Response Prevention. ERP involves working with a trained professional to be able to cognitively challenge the obsessions thoughts that create anxiety and work on a plan to expose ourselves to the feared situations in a structured way without resorting to the compulsions that we normally use to help reduce anxiety. When we are able to expose ourselves to the feared situations while withholding from the compulsions, our perception of threat begins to change, ultimately changing our anxiety response.
Why exposure? Going back to the understanding that anxiety is formed two different ways, the amygdala based anxiety cannot be changed through cognitive thought. It is quite common with OCD for someone to know that their fears are irrational, however, have massive anxiety spikes when exposed to them. If the amygdala based anxiety could be changed with thought then it is fair to say that if someone understood that something was irrational, it would no longer create an anxiety response. When we expose ourselves to feared situations, it allows us to be able to figure out if what we think will happen, actually happens.
Why response prevention? When we experience anxiety, we often find ways to help cope with the anxiety. These ways, such as the compulsions listed above, help temporarily relieve the symptoms of anxiety but offer a "false hope" of anxiety relief. These compulsions or avoidance techniques also restrict us from the exposure process and letting us figure out if what we think will happen, actually will happen. Unfortunately performing these avoidant coping techniques does not allow us to have a learning experience that will ultimately reduce our anxiety.
Why exposure? Going back to the understanding that anxiety is formed two different ways, the amygdala based anxiety cannot be changed through cognitive thought. It is quite common with OCD for someone to know that their fears are irrational, however, have massive anxiety spikes when exposed to them. If the amygdala based anxiety could be changed with thought then it is fair to say that if someone understood that something was irrational, it would no longer create an anxiety response. When we expose ourselves to feared situations, it allows us to be able to figure out if what we think will happen, actually happens.
Why response prevention? When we experience anxiety, we often find ways to help cope with the anxiety. These ways, such as the compulsions listed above, help temporarily relieve the symptoms of anxiety but offer a "false hope" of anxiety relief. These compulsions or avoidance techniques also restrict us from the exposure process and letting us figure out if what we think will happen, actually will happen. Unfortunately performing these avoidant coping techniques does not allow us to have a learning experience that will ultimately reduce our anxiety.
What makes anxiety stick around?
There are three things that perpetuate the cycle of anxiety and interrupts the opportunity for our mind to learn that our feared situations are not as dangerous as our anxiety mind may think they are. AKA, anxiety gets worse instead of anxiety getting better. I term these the "false hope" of anxiety relief. While they can create some level calm, it is very short lived and we have to reengage in one of these tactics when the situation or thought reemerges (because it will).
Avoidance - Anxiety's best friend, your worst enemy. Avoidance is a huge contributor to increasing anxiety levels and for situations to become increasingly more fearful over time. When we avoid situations, thoughts, images, etc, we are reinforcing to our brain that there is significant danger in whatever we experienced. For instance, if we were anxious about social situations and we avoid social situations, it reinforces to our brain that social situations are a very dangerous thing that we need to avoid at all costs. Over time, unfortunately, the anxiety levels increase, making it more difficult to manage social situations when we are required. Compulsions with OCD also fall into the category of avoidant ways of coping with the fears. For instance, I can avoid getting sick by washing my hands constantly. ERP focuses on exposing ourselves to these feared situations to find out if all of the awful things that are brain thinks will happen actually come true.
Distraction - Do we really think we can just "not think about it?" When we distract ourselves from thoughts and worries because they are "dangerous" or "bad," the anxious response is reinforced. We don't allow our mind to fully have and embrace whatever "bad" thoughts that are there and never really get the learning experience to figure out if the bad things that we think will happen if he focus on these thoughts, actually happens. When we use distraction, we are reinforcing for our mind that these thoughts are really dangerous and thank goodness we didn't really think about them, otherwise that would be bad. Fully focusing on whatever is present is extremely important during the exposure process to make sure that we are fully facing the fearful thought head on.
Reassurance - The everlasting unsatisfactory answers from others. "Are you sure that everything will be okay?" "Are you sure that I am not going to get sick?" "If this was going to happen, it would have happened already. I should be safe, right?" "Am I a bad person if I have XYZ thought?" Often with OCD and anxiety, family members and loved ones are berated with questions that are designed to not get an answer, but to help reduce the person's worries about the situation. However, regardless of how many times the question is asked (and answered), the relief in anxiety is temporary and the person often has to asked the same question again to receive the anxiety relief. This is a vicious cycle that unfortunately never gives the person long-term anxiety relief and often strains relationships with others.
**It is also important for family members and loved ones to know why providing reassurance can be detrimental for the process of recovery and how they should respond in times when they are asked for reassurance. It is natural for us to want to answer the questions that our loved ones have in an attempt to comfort them, however, unfortunately it reinforces the "scariness" to the thoughts and worries.**
Avoidance - Anxiety's best friend, your worst enemy. Avoidance is a huge contributor to increasing anxiety levels and for situations to become increasingly more fearful over time. When we avoid situations, thoughts, images, etc, we are reinforcing to our brain that there is significant danger in whatever we experienced. For instance, if we were anxious about social situations and we avoid social situations, it reinforces to our brain that social situations are a very dangerous thing that we need to avoid at all costs. Over time, unfortunately, the anxiety levels increase, making it more difficult to manage social situations when we are required. Compulsions with OCD also fall into the category of avoidant ways of coping with the fears. For instance, I can avoid getting sick by washing my hands constantly. ERP focuses on exposing ourselves to these feared situations to find out if all of the awful things that are brain thinks will happen actually come true.
Distraction - Do we really think we can just "not think about it?" When we distract ourselves from thoughts and worries because they are "dangerous" or "bad," the anxious response is reinforced. We don't allow our mind to fully have and embrace whatever "bad" thoughts that are there and never really get the learning experience to figure out if the bad things that we think will happen if he focus on these thoughts, actually happens. When we use distraction, we are reinforcing for our mind that these thoughts are really dangerous and thank goodness we didn't really think about them, otherwise that would be bad. Fully focusing on whatever is present is extremely important during the exposure process to make sure that we are fully facing the fearful thought head on.
Reassurance - The everlasting unsatisfactory answers from others. "Are you sure that everything will be okay?" "Are you sure that I am not going to get sick?" "If this was going to happen, it would have happened already. I should be safe, right?" "Am I a bad person if I have XYZ thought?" Often with OCD and anxiety, family members and loved ones are berated with questions that are designed to not get an answer, but to help reduce the person's worries about the situation. However, regardless of how many times the question is asked (and answered), the relief in anxiety is temporary and the person often has to asked the same question again to receive the anxiety relief. This is a vicious cycle that unfortunately never gives the person long-term anxiety relief and often strains relationships with others.
**It is also important for family members and loved ones to know why providing reassurance can be detrimental for the process of recovery and how they should respond in times when they are asked for reassurance. It is natural for us to want to answer the questions that our loved ones have in an attempt to comfort them, however, unfortunately it reinforces the "scariness" to the thoughts and worries.**