www.BeTreatedWell.com OCD
Obsessive-Compulsive Disorder has two components,Obsessions and Compulsions,
though not everyone with OCD identifies with having both.
Many people will report compulsions without obsessions: “I just feel like I have to
do it”, or, “I just have to do it until it ‘feels just right’”. Another group report
obsessions only: “I just can’t get the thought out of my head”. When these
obsessions do occur, they tend to have common themes, usually involving:
violence; sex; and religion.
Clinically speaking, obsessions are intrusive thoughts or images that are
distressing. The most common obsessional themes are cleanliness, doubts about
safety, order & symmetry, and aggressive, horrific or sexual imagery. Sometimes
the person realizes that the thought is not logical or distressing to the average
person: “I know that other people don’t worry about getting HIV from touching a
railing at the mall”. Yet others struggle with reasonable obsessions that other
people would agree should be of concern: “what if the lamp cord will start an
electrical fire?”
Compulsions are rituals used to decrease the distressing anxiety produced by the
obsessions. Common among the compulsions are cleaning or washing rituals and
checking. Less observable compulsions include avoidance of situations or settings
which heighten the obsessions such as not using a public restroom or having a
loved one open the mail or lock the house, and reassurances like asking directly
“Did I hit that person that was standing at the bus stop?”, or mentally self
assuring “I know that I did not write something blasphemous in that e-mail”.
Though they may ‘work’ short term, paradoxically compulsions worsen and
strengthen the OCD. The vicious circle of obsessions and compulsions is like a
monster that demands to be fed or a bully that demands your lunch money.
Compulsions of avoidance and mental reassurance are often hard to identify, as
are mental attempts to not think or worry about the thought or image. The
immediate internal response of mental compulsion of trying to neutralize or reject
the thought or is like the spontaneous and regrettable act of yanking on opposing
ends of a string in order to get a knot out.
The essential feature which distinguishes diagnosable OCD from obsessions and
compulsions which are helpful is not the content of what we think and what we do,
but the level of distress and amount of disruption associated with the symptoms.
There is one and only one empirically supported treatment for OCD and that is
Exposure with Response Prevention, with research showing that ERP is
successful in managing OCD in 85% of cases with an average improvement of
50-80%.
The practice of exposure with response prevention (ERP) involves systematic
exposure to a hierarchy of situations and total resistance to the urge to perform a
response to neutralize the distress. ERP is facilitated by an understanding of 1)
the irrationality of obsessions and/or compulsions and 2)the concept of short-term
discomfort needed for long-term anxiety relief.
In order for the exposure to be effective it must be frequent and prolonged. The
exposures can be graded which increases compliance and success.
In order for the response prevention to be effective it must be total response
prevention.
Exposure is based on the fact that anxiety usually goes down after long enough
contact with something feared. Thus people with obsessions about germs are told
to stay in contact with "germy" objects (e.g., handling money) until their anxiety is
extinguished. The person's anxiety tends to decrease after repeated exposure until
he no longer fears the contact.
For exposure to be of the most help, it needs to be combined with response or
ritual prevention (RP). In RP, the person's rituals or avoidance behaviors are
blocked. For example, those with excessive worries about germs must not only
stay in contact with "germy" things, but must also refrain from ritualized washing.
Exposure is generally more helpful in decreasing anxiety and obsessions, while
response prevention is more helpful in decreasing compulsive behaviors. Despite
years of struggling with OCD symptoms, many people have surprisingly little
difficulty tolerating ERP once they get started.
The goal of ERP is to tolerate increasing amounts of uncertainty. The goal is not
stopping the obsessions or stopping the compulsions. The goal of ERP is not
‘learning’ that it is okay to not perform a ritual. The goal of ERP is not sharpening
skills of self reassurance via using self-talk such as “If a therapist is telling me to
do this, it must be safe (and effective too).”
When total resistance to the compulsion is impossible the following options are
suggested: Delay; Shorten; Change; Slow down. Other techniques for treating
OCD, such as thought stopping and distraction (suppressing or "switching off" OCD
symptoms), satiation (prolonged listening to an obsession usually using a closed-
loop audiotape), habit reversal (replacing an OCD ritual with a similar but non-OCD
behavior), and contingency management (using rewards and costs as incentives for
ritual prevention) may sometimes be helpful but are generally less effective than
standard ERP.
Obsessive-Compulsive Disorder has two components,Obsessions and Compulsions,
though not everyone with OCD identifies with having both.
Many people will report compulsions without obsessions: “I just feel like I have to
do it”, or, “I just have to do it until it ‘feels just right’”. Another group report
obsessions only: “I just can’t get the thought out of my head”. When these
obsessions do occur, they tend to have common themes, usually involving:
violence; sex; and religion.
Clinically speaking, obsessions are intrusive thoughts or images that are
distressing. The most common obsessional themes are cleanliness, doubts about
safety, order & symmetry, and aggressive, horrific or sexual imagery. Sometimes
the person realizes that the thought is not logical or distressing to the average
person: “I know that other people don’t worry about getting HIV from touching a
railing at the mall”. Yet others struggle with reasonable obsessions that other
people would agree should be of concern: “what if the lamp cord will start an
electrical fire?”
Compulsions are rituals used to decrease the distressing anxiety produced by the
obsessions. Common among the compulsions are cleaning or washing rituals and
checking. Less observable compulsions include avoidance of situations or settings
which heighten the obsessions such as not using a public restroom or having a
loved one open the mail or lock the house, and reassurances like asking directly
“Did I hit that person that was standing at the bus stop?”, or mentally self
assuring “I know that I did not write something blasphemous in that e-mail”.
Though they may ‘work’ short term, paradoxically compulsions worsen and
strengthen the OCD. The vicious circle of obsessions and compulsions is like a
monster that demands to be fed or a bully that demands your lunch money.
Compulsions of avoidance and mental reassurance are often hard to identify, as
are mental attempts to not think or worry about the thought or image. The
immediate internal response of mental compulsion of trying to neutralize or reject
the thought or is like the spontaneous and regrettable act of yanking on opposing
ends of a string in order to get a knot out.
The essential feature which distinguishes diagnosable OCD from obsessions and
compulsions which are helpful is not the content of what we think and what we do,
but the level of distress and amount of disruption associated with the symptoms.
There is one and only one empirically supported treatment for OCD and that is
Exposure with Response Prevention, with research showing that ERP is
successful in managing OCD in 85% of cases with an average improvement of
50-80%.
The practice of exposure with response prevention (ERP) involves systematic
exposure to a hierarchy of situations and total resistance to the urge to perform a
response to neutralize the distress. ERP is facilitated by an understanding of 1)
the irrationality of obsessions and/or compulsions and 2)the concept of short-term
discomfort needed for long-term anxiety relief.
In order for the exposure to be effective it must be frequent and prolonged. The
exposures can be graded which increases compliance and success.
In order for the response prevention to be effective it must be total response
prevention.
Exposure is based on the fact that anxiety usually goes down after long enough
contact with something feared. Thus people with obsessions about germs are told
to stay in contact with "germy" objects (e.g., handling money) until their anxiety is
extinguished. The person's anxiety tends to decrease after repeated exposure until
he no longer fears the contact.
For exposure to be of the most help, it needs to be combined with response or
ritual prevention (RP). In RP, the person's rituals or avoidance behaviors are
blocked. For example, those with excessive worries about germs must not only
stay in contact with "germy" things, but must also refrain from ritualized washing.
Exposure is generally more helpful in decreasing anxiety and obsessions, while
response prevention is more helpful in decreasing compulsive behaviors. Despite
years of struggling with OCD symptoms, many people have surprisingly little
difficulty tolerating ERP once they get started.
The goal of ERP is to tolerate increasing amounts of uncertainty. The goal is not
stopping the obsessions or stopping the compulsions. The goal of ERP is not
‘learning’ that it is okay to not perform a ritual. The goal of ERP is not sharpening
skills of self reassurance via using self-talk such as “If a therapist is telling me to
do this, it must be safe (and effective too).”
When total resistance to the compulsion is impossible the following options are
suggested: Delay; Shorten; Change; Slow down. Other techniques for treating
OCD, such as thought stopping and distraction (suppressing or "switching off" OCD
symptoms), satiation (prolonged listening to an obsession usually using a closed-
loop audiotape), habit reversal (replacing an OCD ritual with a similar but non-OCD
behavior), and contingency management (using rewards and costs as incentives for
ritual prevention) may sometimes be helpful but are generally less effective than
standard ERP.
| Antonia Caretto, Ph.D., PLLC |
| www.BeTreatedWell.com phone: 248.553.9053 |
| Articles of Interest: Business of Therapy Anxiety Why Gender? Asperger's Disorder Adjustment Disorders Self-Injurious Behavior |
