Obsessive-compulsive disorder (OCD) is an anxiety disorder that can cause significant damage to the sufferer’s life. OCD begins with obsessive thoughts. These lead to the development of behaviors meant to control the thoughts. The behaviors then become compulsive rituals. The person feels strongly compelled to perform the rituals in response to the disturbing thoughts, even though relief may be very short-lived. Serious trouble with relationships, self-confidence, depression, quality of life and, perhaps, a related or other disorder in addition to the OCD, often accompany the disorder. OCD can make life a non-productive, empty, frustrating, and lonely endeavor. There is evidence that OCD is caused by a brain dysfunction and that the most effective treatment is a combination of an antidepressant and cognitive-behavioral therapy (CBT).
Dan was 29 years old when he decided to find out what he could do about his obsessive compulsive disorder, if anything. He had suspected he had it for about five years, when he saw a television special on OCD, but had known that there was something very wrong since his early teens: The double-checking, triple-checking and so on were a tip-off. He knew it was strange and very frustrating, but didn’t know what it was. The program explained that the ritualistic behaviors are compulsions developed by people with OCD to fend off distressing, obsessive thoughts.
Dan was afraid of becoming ill or being otherwise hurt and he could obsess on those thoughts for hours and even days. In high school, he had found that if he checked that the lights and stove were off before he left for school in the morning a certain number of times, he could fend off the obsessive thoughts so that he could make it to school on time. Otherwise, he might be a few minutes, an hour, or even several hours late. The checking was compulsive: At one point, he couldn’t make himself leave his house without checking on the lights and stove 67 times, and he couldn’t leave school to go home without checking to make sure he had all of his homework and books 27 times. Otherwise, his anxiety about becoming ill or hurt in some serious way became so overwhelming that he thought the anxiety alone would kill him.
Dan waited five years after seeing the television program to seek help for his OCD because he was extremely embarrassed by his obsessions and compulsive behavior. He tried, on his own, to substitute more pleasant thoughts for the obsessive ones. He tried to talk himself out of the obsessive fears, and he tried other, less time-consuming and more productive routines to distract himself. It seemed that each time he tried these changes, his anxiety would rise and he found he couldn’t stop himself from performing the rituals to ward off his panic. He would become frozen at even the thought of exposing himself to new germs from people he didn’t know. He was afraid to ride in a car with anyone else driving, and he was afraid of answering his door when someone knocked. While he struggled to control the fearful obsessive thoughts, they multiplied.
By the time he sought help, Dan had been depressed for over two years, stuck in a dead-end job he didn’t like for six years and had just two friends he had known all of his life. He didn’t date, go to new places or ever try new foods, afraid of exposure to germs and other health risks. He had to rise two hours before he would otherwise have to, before going to work, in order to check the lights and stove many times. He was fearful of others finding out about his strange behaviors and so he avoided closeness with others. His life was a torment.
Dan was much like the 2 to 3% of the U.S. population estimated to have 0bsessive-compulsive disorder (National Institute of Mental Health, 2000). Dan saw a psychiatrist and the diagnosis were confirmed. The psychiatrist explained that OCD is a type of anxiety disorder and explained it to him. Dan thought the diagnosis certainly fit. He was somewhat relieved to hear that many people have it, and many learn to overcome it or effectively manage it.
Although Dan had some idea that his obsessive fears were not rational, the psychiatrist confirmed it. She prescribed Paxil (paroxetine), an antidepressant that also has anti-anxiety properties, and said these should help with both the depression and the obsessive thoughts. She recommended two therapists in town who could provide behavior therapy (BT) or cognitive behavioral therapy (CBT) to help him further. She explained that, together, the outcome would likely be the best for helping Dan become free of the obsessive thoughts, his need for rituals to ward off the thoughts and the resulting depression.
Dan began to feel hopeful, but understood it would take time for the medications and therapy to show results. The psychiatrist warned him not to expect too much too soon, to work at his therapy and not to discontinue the medications. She said that if this medication didn’t work for him, she would definitely want to help him taper off and try another one, as not all bodies react in the same ways to these medications. If he abruptly stopped on his own, she said, he could become physically ill. Once a medication was working, and then if he decided to discontinue them, he would begin to have the obsessive thoughts again.
He wasn’t sure he wanted to be on medication the rest of his life and wondered if there wasn’t another way to address the disorder. He began the medication, though, and made an appointment to see one of the recommended therapists. The therapist proposed something called exposure and ritual prevention, also known as exposure and response prevention, or ERP. He said this is a highly recommended therapy and is related to BT and CBT. Dan asked if this would work without the medication, but the therapist was very doubtful. He said that both are usually needed. Dan agreed to try it.
Dan’s therapist convinced him to start conservatively in his therapy assignments. Dan agreed that he would try to walk to his neighborhood grocery three times the next week to pick up things he needed, like bread, milk, and the newspaper, without checking the stove, lights, or anything else at home. He didn’t make it the first two times he tried, but the day before the next therapy session, he was able to reach the store and buy milk before hurrying home to check on things. That was 10 days after beginning his medication. The psychiatrist had told him that it took awhile to start working. He was gradually able to make the trip three times in one week without any checking.
The therapist then suggested he try to go to work one day without checking those things. Some days he could almost make it to work without having to turn back in a panic. He was feeling less depressed and even more hopeful, though, so kept trying. Eventually, he was able to go to work without the checking on a regular basis, but some days were harder than others.
The therapist encouraged Dan to enroll in a class in photography held at a nearby college, something Dan had told the therapist he’d thought about doing for years. He enjoyed the class and was feeling optimistic about his life in general. Toward the end of the class, he mustered enough courage to ask a woman in the class for a date. They began dating on a regular basis, and told the therapist he was happier than he had ever been in his life.
Dan later became friends with a fellow at work who was planning on starting his own business. Dan was excited when he asked Dan to come to work with him. It was a good opportunity and he was looking forward to it. He realized his dread and panic were almost gone. He found that if he got enough rest, took his medications, and took one step at a time, he could control his thoughts about illness and other harm to himself. There were still some of those thoughts, but they didn’t control him any longer. He controlled them.
The cause of OCD
No one has been able to prove one cause of OCD, or any anxiety disorder for that matter, but there is strong agreement among scientists that the chemical brain substance, serotonin, is involved: Since the anti-depressants called SSRIs (selective serotonin reuptake inhibitors) usually help people with OCD decrease their habitual compulsions, this makes sense to most researchers. Brain scan evidence of dysfunction in the frontal cortex of people with the disorder has been documented for many years.
It appears that OCD often runs in families, so may be carried by a gene. Some scientists believe there is enough evidence to show that it can also be a result of an earlier streptococcal infection, and others that it might be a result of a male hormone imbalance.
In general, people often think that a symptom of a psychiatric disorder is a clue concerning the cause of the disorder. This seems to make sense, but is often incorrect. For instances, a person with a mood disorder may not be clinically depressed because something sad, difficult, or disappointing has happened to him; a person with a psychotic disorder who hears punitive messages from God, called audio hallucinations or voices, may not have something to feel seriously guilty about and may even know they don’t and; similarly, with OCD, a person’s obsessive thoughts may have nothing to do with anything that has happened to her or him.
It’s natural to think about why the thoughts may be occurring and to attach what seems like a reasonable explanation to them. It’s also common to assign underlying reasons for the particular rituals of OCD, whether true or not. It’s understandable that some people with OCD, and people close to them, attribute the nature of the rituals to the content of the obsessive thoughts. However, they aren’t always related in obvious ways.
Here is an example of a person who has decided she knows the cause of her obsessive thoughts, even though they may not be a result of the incident described in whole or even in part. Sally had obsessive thoughts about sexual deviance. She was plagued by the thoughts, and embarrassed. She blamed herself for them, thinking she must be a bad person by nature. After all, her parents had been good to her and her sisters, and no one else seemed to have such thoughts in the family. However, there had been an uncle who had sexually abused her once when she was a young teenager. She had told no one. She hadn’t accepted that she was just a child at the time, so afraid that she felt she had no choice, and that she was a victim. The abuse and the fact that she kept it a secret could have contributed to her obsessive thoughts, but may not have had anything to do with the thoughts. It’s easy to imagine that they could be related because both involve sexual deviance. The evidence that most people who were sexually abused as children do not have those obsessive thoughts and that some who were not abused as children have such obsessions suggests otherwise.
Here’s the story of another person who thinks the reason for his obsessions has something to do with a childhood event. Frank had obsessive thoughts of harming another person, although he has never done so as an adult and doesn’t plan on it. He was sure the thoughts came a time when he beat up his brother. They were both young children of six and eight years old and he had been punished by his mother. She told him he should be ashamed of beating up someone younger than himself. He was sent to his room for the afternoon. That event and his obsession, including the content of his obsession, are probably not related.
Here’s an example of someone who is sure her rituals developed because of her depression. Maria was comforted by counting the times she touched a door knob before going through a door. She had decided that to go through a door at work, she needed to touch the door knob eight times. She felt better; more relaxed, and as if this would ensure her of not making a mistake at work. She was careful not to let others at work see her doing this and would wait until they weren’t looking to go to another room. Her co-workers saw only that she was slow to get some things done and they thought it was lack of confidence that held her back. Maria knew she felt very sad most of the time, and never felt the joy she remembered having from time to time in her past. She was depressed. The reason for both Maria’s depression and the ritual were her obsessive and irrational thoughts about doing her work perfectly, an obsession. On the other hand, she knew she was good at her work and received many compliments from her supervisor and co-workers. She just didn’t realize that the frustrating ritual, secrecy in which she performed the ritual and her perfectionistic obsession were probably responsible for a resulting depression.
In this example, Jannie thought she was a hoarder because she grew up poor: She attributed her hoarding ritual to that childhood poverty. She knew that saving worn-out clothes, shoes, and household items was filling up all of the rooms in her house, but she felt comforted by saving things and was sure she would have a need for them later. Her closets overflowed with bags of things she was saving. She had started to store full bags under tables and chairs too. She couldn’t walk into her garage because of the bags stacked taller than she was. Yet, her obsessive thoughts were about something different: that she was in danger and about to die. It’s easy to understand why she thought she was hoarding, and it may even have been part of the reason. She didn’t know that many other people with OCD who hoard did not grow up poor, and they had various obsessive thoughts. Her earlier poverty may, though, be a contributing factor.
Richard said he kept all of his old newspapers and magazines because he planned to write a book on American culture some day. He felt afraid that he would miss some of the most important events and trends if he didn’t keep these records, and in a certain order. He was aware that he could always go back and check library records for these articles, but felt more assured knowing they were right there in his own house. He became very anxious at the thought of throwing any of the materials away and knew this was irrational. Richard had never been poor and didn’t have obsessive thoughts related to being poor. His obsessions were about becoming infected with germs from another person. Although he admitted to being lonely, he couldn’t bear the thought of moving the written materials for a guest since the materials would then be out of the order he would need them in for writing the book. He may have been right to wonder if his hoarding was really his way of keeping others away from him since he worked from home and never had people there. His hoarding might be, at least partly, due too to his efforts to feel better about himself by writing an admirable and admired tome. His father admitted to obsessive thoughts about germs, would not eat in restaurants for that reason and, earlier in life, was able to overcome a habit of compulsive hand washing.
Most people with OCD sometimes recognize that both their obsessions and compulsions are irrational. Yet, it’s understandable that individuals’ theories concerning causes of their OCD are often that it’s learned behavior, a result of an event or circumstances, or related to psychological factors or conditions. Alternatively, people from certain religions and cultures, or sub-cultures, may believe it’s a result of punishment by God, a curse placed on them by an enemy or something like seeing a bat flying in the daytime. It’s human nature to look for explanations and to feel some satisfaction in determining a cause.
The natural assumption is to surmise that the cure lies in addressing the cause: Believing it’s a punishment by God may lead to more praying; believing it’s a curse might mean that one should initiate some magical counteraction; belief that seeing a bat flying in the daytime is the cause of the OCD might prompt a belief that one should only function in the nighttime to be rid of the OCD. Culture and religion may influence the content of OCD obsessions and rituals (Oshaka, 2004), but seem not to be a cause or related to a cure that yields the best result for most people.
Again, Western science tends to agree that OCD is the result of brain dysfunction. Whatever theory you adhere to, overcoming the disorder is most frequently achieved by taking an antidepressant and actively participating in cognitive behavioral therapy.
People with OCD frequently have other disorders or issues too, such as: panic attacks, Tourette’s Syndrome, phobias, depression, dyslexia, attention deficit disorder, an eating disorder or another anxiety, learning or depressive disorder; sexual dysfunction; addiction; dependent personality disorder; and/or guilt. All of these are being researched, particularly in relation to disordered regulation of serotonin in the brain.
Unlike a person with obsessive compulsive personality disorder, the person with OCD knows that her or his obsessive thoughts and ritualistic compulsions are irrational and is upset by them. The obsessions in OCD frequently concern extreme worries about harm to self or others, death, religious themes, or sexuality. The rituals may have nothing to do with the worrying thoughts; for instance, a person with OCD may count a certain number of objects before leaving his home in order to manage recurring and disturbing sexual thoughts. Conversely, the ritual may be related to the disorder; for example, excessive washing of hands to distract from recurring and irrational thoughts about the dangers of germs.
People with OCD do not have any delusions about where the thoughts are coming from. They know they are a product of his mind. The disorder has been called, “The doubting disease.” The person feels she or he must perform the ritual in an exacting manner in order to lessen the anxious obsessions before she or he can move on to other activities. According to the Diagnostic Statistician’s Manual (DSM), the guide developed and used by North American psychiatrists for diagnoses, the compulsions must use up at least one hour per day in order to be diagnosed with OCD. A diagnosis of OCD also requires that everyday life is disrupted by the compulsions. To meet the criteria for this diagnosis, the compulsions are not a part of another disorder, such as a compulsion about eating that is part of an eating disorder. The compulsive ritual cannot be the result of taking a drug, either, for a diagnosis of OCD (1995). OCD can become so overwhelming that the person can hardly do anything but perform the compulsive behaviors.
Jill was an educated, thirty-six year old mother of two when she began to obsess that she would die and leave her children motherless. She developed a ritual to distract her from the thoughts and, when it was completed, felt like she could safely continue with whatever life tasks she needed to do. She would count all letters in words within her sight and if they didn’t add up to an even number, she would then search another room for words and count the letters there until she had counted them all. If the number was still not even, she would do the same in another room and so on, until she came up with an even number after counting in that room. Until she did this, she would not leave the house and drive anywhere, afraid she would be killed in an accident. To Jill, the counting to an even number was an annoying, but required, habit before she could feel safe enough driving. Her husband teased her about always being late, although didn’t know why she went from room to room so frequently. She felt humiliated. Jill tried to make light of it, but secretly berated herself for her “strangeness.” Her husband sometimes became angry at what he called her, “procrastination” in getting things done. The woman he married had always been a perfectionist, but she accomplished what she set out to do. He finally convinced her to see a psychiatrist when she was consistently late getting her eldest daughter to pre-school and broke down in tears with him, saying she didn’t know what to do.
After checking for obsessive compulsive personality disorder and any other possible disorders, the psychiatrist assured her that some medication and therapy would help her. She was so relieved to put a name to her problem that she cried with joy, but she felt very frightened when the psychiatrist added that she would help Jill face her fears.
Joe felt driven to touch the handle of his front door 182 times before opening it. He was told by co-workers to stop touching their collars before he spoke to them at work and some just stayed away from him when he didn’t stop. His supervisor finally told him to, “Shape up or get out.” Joe liked his work and his co-workers, but he worried that he would shout out his greatest recurring fear, that they would die while talking with him. He knew the thoughts and touching rituals were, “crazy,” but he didn’t know what to do.
He had a trusted MD he had seen for several years and decided to ask him about it. The doctor was reassuring; telling Joe he could get help through a psychiatrist and that he understood that many people had been successful with such help. Sure enough, the psychiatrist diagnosed Joe with OCD. He told Joe that his grandmother’s need to wash her hands repeatedly, until raw and bleeding, was probably OCD too. Joe was surprised to hear that a gene he may have inherited could be the cause of his OCD.
Ellie’s mother took her 12-year old daughter to a psychologist when she saw that Ellie was hoarding food in her room and wouldn’t stop when told to. Ellie had cried and tried to explain that God didn’t love her, no matter how good she tried to be and she couldn’t stop thinking about that unless she stored food in her room. Her mother thought Ellie must have some kind of psychotic illness, but the psychologist disagreed and recommended that Ellie see her once per week for awhile and see a medical doctor for possible medication. The psychologist said she believed Ellie had OCD. Both Ellie and her mother were glad to have a name for it. Ellie learned that many other people have the same problem.
Hoarding, counting, arranging items in particular ways and touching can be signs of OCD if there are disturbing recurrent thoughts behind these actions. The actions must be carried out to an exacting and excessive degree and the purpose of the rituals must be meant to ease the anxiety of obsessive thoughts. George was astounded when he went to his son’s school counselor to talk about the boy’s tattling and bad language. George had talked with his son and knew that he tattled because he had a very rigid idea about what was okay behavior and what was not. George thought the issue had disappeared. He particularly didn’t understand why the boy would alienate himself from the other kids by tattling all the time, and swear in school since he knew that wasn’t okay behavior. The counselor said it might be Tourette’s Syndrome, but referred him to a psychiatrist. When George took his son to the psychiatrist for the third visit, the psychiatrist said he was sure the boy had Tourette’s and OCD. He explained that the two are sometimes diagnosed together, and some doctors believe they are physiologically related. George was happy to hear that there is treatment for both. His son was extremely pleased that his father apologized to him for badgering and punishing him for the tattling and swearing. The boy was relieved that his father and the doctor would help him get rid of his terrible, anxious thoughts about death and the swearing tic that so embarrassed him too.
Some people with OCD hide the disorder so well that even those close to them don’t guess that they are carrying out compulsive behaviors. Others may seem a bit strange, or quirky, rigid or perfectionistic. Still others may perform the compulsive behaviors only in their heads, such as counting to a certain number: Some people have only the obsessions, without the compulsions.
Help for OCD
A psychiatrist, psychologist, therapist or another counselor experienced with diagnosing OCD will almost always recommend medication, usually an anti-depressant, in addition to behavioral therapy. Medication can be prescribed only by a doctor, a psychiatrist (who is also a doctor) or a prescribing nurse. Therapy for OCD begins in the therapist’s office.
The lack of enjoyment, fulfillment, and productivity of a life with OCD is likely to be referred to again and again throughout therapy to remind the person of why he or she must face and deal with the disorder. In therapy, too, the professional will probably discuss how the obsessive thoughts are a manifestation of anxiety, and the ritualistic behaviors only dispel the obsessive thoughts for a short while. The fears of what will happen without the rituals will also be a topic of discussion, as will the groundless nature of the obsessive thoughts. The therapist will gently challenge the client with OCD with such discussions more than once or twice as the person struggles to remain in recognition that he or she can become stronger than the disorder.
The therapist may also have the person with OCD write a list or tape record descriptions of what makes them anxious. Then, the person will be asked to read or listen to the list frequently while not reacting, thus desensitizing the person to those stressors. Since anxiety can only be maintained for a certain period of time, this can work to decrease future anxiety in the face of those circumstances. This is a method for helping people overcome phobic disorders as well.
It is frequently difficult for a professional to help the person sort out the reason, or reasons, for a ritual from what the person believes is the cause; and the professional often spends significant time helping the person accept that the obsession was not caused by, or is only partly related to, a real event. Using rational explanations for irrational thoughts and rituals may be legitimate in some cases of psychiatric disorder, but with OCD, they are either not related or only one of the contributing factors.
In many cases, wading through all of the person’s explanations for her or his OCD can be time-consuming and frustrating for the individual with OCD. The issues of lack of self-confidence, perfectionism, ambivalence, rumination and avoidance that are characteristic of OCD can complicate progress towards facing the facts of the physiological origin of the obsessions and resulting development of ritualistic habits that the person feels compelled to perform. Spending a lot of time on talking about causation can actually impede progress by feeding into the self-confidence issues (making the person feel even more a victim with no or little control), perfectionism (finding the perfect explanation and, thereby thinking they have found a perfect solution, when the explanation and solution may actually be completely incorrect), ambivalence (doubt about what the condition is and what to do about it), rumination (over-thinking) and avoidance (running from the fears one must face to overcome or deal with OCD). Some therapists don’t spend much time at all on such discussions, for those reasons. In order to move more surely towards the process of helping the individual deal effectively with the obsession(s) and extinguish the rituals, the person must trust the therapist enough to listen and agree to follow through on the necessary steps to recovery.
However, trust in another person is often very difficult for the individual with OCD. Knowing this, many therapists will engage in some discussion in order to build rapport, while also steering the person toward:
- Recognition of the futility of paying any serious attention to obsessive thoughts
- Accepting the thoughts as unimportant
- Letting go of self-blame for the thoughts
- Knowledge that there is no inherent worth or meaning in the compulsions
- Gradually extinguishing the compulsions
- Withstanding anxiety when in a formerly anxiety-producing situation
- Trusting other people
- Accepting that there is no such thing as perfection
- Decreasing rigidity by increasing flexible thinking and behaviors
- Realizing that neither ruminating or avoidance help, and to give them up
- Making decisions more easily
- Taking charge of her or his life in positive ways
- Developing a habit of giving her or himself ample credit for successes and strengths
The therapist is likely to develop a plan with the person that includes carrying on with a normal daily life during obsessive thinking, but without engaging in the compulsive behavior. However, an experienced therapist will know to begin with small steps and work towards larger challenges. Generally, the professional will help the person choose the least challenging situation first and then the more challenging ones, as the person is successful at the lesser ones; for instance, Dorothy may agree to try to hold her anxiety in check at work twice that week, forgoing her usual need to step over the front door threshold three times before actually leaving. If successful, she may agree to four times the next week. Dorothy will, most likely, be able to leave without any ritualistic behavior in time, and without her obsessive thoughts causing significant anxiety. She may still feel the compulsion, but will have become accustomed to ignoring it.
Let’s say Dorothy is not successful that first week. She might agree to just once the next week. The therapist may help her find some alternative thoughts to the obsessive ones. She’s likely to encourage Dorothy to brave through the anxiety of not performing her ritual. Dorothy will be reminded that berating herself doesn’t help, so she may agree to try replacing the thoughts with a positive one instead, such as, “I have the power to leave now and I will.” The therapist will assist Dorothy to remember to increasingly use that phrase to replace all self-berating or helpless thoughts. The professional may help her visualize herself doing that, and even suggest that Dorothy visualize this a few times during the day before doing it. They may practice it in the therapist’s office too.
Simultaneously, before or after addressing the ritualistic behaviors, the therapist will help Dorothy to deal with her obsessive thoughts with confident calm, rather than fighting with them or retreating in fear and resorting to compulsive behaviors. Rather than trying to fend off the thoughts, thereby making them stronger, the therapist may suggest relaxing when the thoughts occur and just commenting to herself that, “Well, there’s one of those thoughts, but I know it’s meaningless.” The therapist is likely to recommend that Dorothy go about whatever she was doing or planning on doing. With repetition over time, the obsessive thoughts are likely to be disarmed by not allowing them to escalate her anxiety.
Progress can be slower or faster than one would expect. The medications help most people successfully overcome the ritualistic behaviors, probably because they obsess less while taking it. Since the medications are the same ones used for depression, the depression the person may have been experiencing may well lift too. If the particular anti-depressant is working, the person will experience increased energy and will. A therapist may also engage the person in some thinking about their relationships with other people, if that has become a problem, in an effort to help the person develop trust of others.
Rather than thinking, “This person could be carrying germs that will harm me,” or whatever similar obsession the person may have that involves others, the therapist can help the person develop an alternative thought about others. This might be something like, “This person is not sick and I won’t become sick by being near him.” With practice, the alternative thought becomes easier to automatically substitute for the negative obsessive thought.
Another issue concerning others is often the person’s embarrassment about the ritualistic behaviors. In fact, most people with OCD hide the behaviors, a distinguishing feature of OCD, knowing that it would seem strange to other people. The person with OCD often increasingly avoids others, so that they don’t see the behaviors. The therapist may encourage social contact, but will usually suggest that gradual steps be taken towards increasing socialization so that the person has time to become accustomed to being with people. This allows the person to handle the associated anxiety of that contact without it overwhelming him or giving in to the compulsion.
Once people with OCD understand that they have a bona fide disorder and that others have it too, the result is likely to be some increase in self-confidence and fewer feelings of isolation. These feelings can help with building new relationships and improving older ones. If the person has a family, the therapist may engage the family in understanding and supporting the family member with OCD, if the person agrees. This can help the person feel less isolated and decrease the chance that the family will pressure the person too hard or fast, and cause a relapse.
A goal of therapy is often to decrease the person’s perfectionism. The therapist may help the person use some alternate thoughts about how well certain tasks need to be done. A thought such as, “There is no such as perfect,” can be used to replace, “I must make sure there is no possible flaw in this work.” Instead of going above and beyond, the person may eventually be able to draw the line when the task is completed. Perfectionism is an example of rigid thinking. A person with OCD may be especially rigid in other ways too, or instead of being a perfectionist. Other rigidities are also likely to be explored in therapy. Thoughts of, “I must,” “I have to,” and “I should” are likely to be brought out into the open and challenged by the therapist. The therapist may work on helping the person substitute these with more empowering thoughts, for instance; “I want to…” or “I am choosing to…” This changes the dynamics between the person and his or her disorder by putting the person in charge of his or her thoughts, instead of in a victim position. It helps the person to build confidence in making positive decisions for herself.
The therapist may encourage the person to develop recreational, vocational, spiritual, and other life goals to ensure that the person looks at his whole life, examines what he needs and wants from life and works towards those positive life goals. This also has the benefit of distracting the person from obsessive thoughts and compulsive behaviors. This engagement in life is antithetical to the OCD that has been robbing the person of a fulfilling, enjoyable, productive and meaningful life. In turn, taking part in steps towards a better quality of life will also help the person gain and maintain self-confidence. The importance of that self-confidence to reaching further goals concerning life enhancement and learning to manage the OCD cannot be overestimated.
If the person with OCD has a related or other disorder, in addition to the OCD, this can also be addressed in therapy. This can be more complicated. The therapist will work out a treatment plan that doesn’t burden the person with too many goals and associated tasks at one time and contain any conflicting goals and tasks for the person. A good plan will reflect careful consideration of the nature of both disorders and each in relation to the other. Alternatively, the therapist may choose to work on one of the disorders before the other. The therapist might consult with a psychiatrist or another therapist in developing the plan, and may recommend a group and/or other additional types of therapy too.
It’s common practice to involve the person with the disorder in creating the plan. This can be helpful to creating a plan that the person will follow through with, as long as the person agrees to the essential therapy elements recommended by the therapist. The individual must be willing to experience some anxiety while doing this, but can help pace the progress to her or his tolerable levels of anxiety.
Methods of self-help
By looking at the areas that people who have OCD struggle with the most, we can begin to see that there are many methods that people with the disorder can carry out on their own to manage the disorder. These shouldn’t be considered substitutes for medication and therapy, but may be helpful both during and after successful therapy. Again, it is not recommended that the medication be discontinued since the vast majority cannot maintain their recovery from OCD without it. We’ve discussed obsessions, compulsions, trouble with relationships, lack of self-confidence, avoidance, ambivalence, perfectionism, ruminations, depression, and quality of life: Taking these separately, we’ll next consider some ways the person with OCD can address them.
There are several tactics for managing obsessive thoughts. These recurring and often disturbing thoughts become more powerful if the person ruminates on them. Rumination means thinking the thoughts over and trying to figure out where they’re coming from and what’s causing them. It can also include becoming frustrated and angry at the self for having the thoughts. The person may blame herself, or himself, for the thoughts. Doubts about whether he or she is a good person, because of the thoughts, are common.
One of the ways to stop or manage obsessive thoughts is to remember that they are only misfiring synapses. Synapses are the conductors of the brain that relay messages. You are not responsible for those synapses misfiring.
What is the nature of your disturbing thoughts? Think this through. You know the thoughts aren’t valid and this can work for you if you’ll remind yourself frequently that the thoughts do not reflect reality. Will you really die or become extremely ill if someone touches you? It’s very unlikely. Are you seriously considering hurting some else? Of course not. (If you ever really think of a plan to do so, it’s not the obsessive-compulsive disorder and you need to tell a professional right away.) Do you really believe that your unusual sexual thoughts can make you act that way? No, you know better. Whatever the obsessive and disturbing thoughts, you are the one in control of your behavior and you can quiet those thoughts by repeatedly using your reasoning powers to defuse them.
The obsessive thoughts do not need to be obsessive. With medication, most people can learn to accept when they have a weird thought as just a physiological phenomenon. Thinking, “Oh, there’s that thought again. Oh, well,” is a choice that can be made each time it happens. In time, this will diminish the frequency of the thought, or thoughts, and the “Oh, well” attitude will become automatic.
Practice with a few different and accepting phrases, either out loud or just thinking them, to tell the brain that you’re not going to fall back into obsessing again. You can use, “Oh, well,” or find one that suits you better. It must be a phrase that tells your mind that it’s no big deal.
You can also delay your response to the thought. Telling yourself that you’ll deal with it at 7:00 PM, much as a good parent tells a child when they will later discuss an issue bothering the child, sends the message to the brain that there is a time and place for it, but not right now. This way, you become in charge of the thought. With practice, you’ll be likely to find that at 7:00 PM, you can tell your mind that it doesn’t seem there’s anything to worry about after all. Meanwhile, you can also put a deadline to the inner discussion too. You can agree with yourself to think the obsessive thoughts and anything else that might be bothering you from, say, 7:00 PM to no later than 7:30 PM. If the thoughts try to continue past 7:30 PM, you can then tell them that you won’t be addressing them until 7:00 PM the next evening, when you’ll give them another half hour. This will become easier with regular practice.
If you can identify when you most frequently have your disturbing thoughts, you can choose to distract yourself with a task or enjoyable activity at that time. You can also prepare ahead of time by planning to soothe yourself with a warm bath, a walk, other physical exertion or your favorite kind of music. Anything that helps you feel calm can make you stronger in the face of those anxious thoughts. Some people find it helps to have a place where they can go to relax without the thoughts, a kind of no-war zone. This can be the corner of the couch, a chair in the garden or anyplace you choose where you won’t allow OCD to interfere.
There are people with OCD who claim that meditation once or twice per day is very helpful to them. This isn’t surprising since meditation has a calming effect on the brain. There are various methods of entering a state of meditation, but the most important aspect of achieving and maintaining meditation is to calmly let all thoughts pass through your mind without dwelling on them until you have a space of time when there are no conscious thoughts. Reaching a meditative state takes time and practice. Listening and participating in a meditation class is the best way to learn it. Meditation can also be helpful to developing the skill for turning off disturbing thoughts at other times as well, but the main point is to give yourself a time free of thoughts.
Remember that the disturbing thoughts are the foe. They are the enemy in your fight for a good life against OCD. You are more powerful than the OCD, so remind yourself of that.
Your compulsive behaviors do not work to rid yourself of the obsessive thoughts for long. In fact, those rituals have joined forces with the obsessive thoughts against you. They steal your most valuable commodity; time to live a satisfying life. There is significant stress involved in experiencing compulsions, just as there is stress in experiencing obsessive thoughts. As part of the OCD, compulsions too are your enemy.
Think about the ridiculous nature of your rituals. You know they don’t cure you. You know they are a curse in themselves. After all, you don’t really believe in magic. You know that there is no good reason to wash your hands again, count every telephone pole you pass or to do whatever your compulsive behavior may be. Recognize this several times per day and tell yourself you have the power to reject the temptation to fall for that habitual compulsion. You do.
Replace compulsions with productive or enjoyable activities that have nothing to do with your old rituals or the disturbing thoughts. When you feel like keeping the magazines and newspapers, adding them to the stacks in your living room, instead throw them out and do some yard work. When you feel like heading to the sink to wash your hands, already washed a few minutes ago, go do your shopping instead. When you think of rearranging your chairs again so that they are perfectly situated, go back and read that great novel you started or start another one.
Live your life. Fill your time with things you want to do. Try to be spontaneous when making a decision that won’t realistically be a matter of life and death. Go ahead and make some mistakes. We all do, no matter how we try not to. This will give you less time for engaging in those old rituals. Get busy doing the things you want to do. If you’ve always wanted to take a yoga class, do it. If you like to fish, go fishing. If you like animals, get a pet. If you want to change careers, go get some training and do it. Do as many things that are productive, enjoyable, or meaningful to you as you want to every day.
Face the fact that you are sometimes very anxious, and then face what you may be realistically worrying about. Is there any validity to it? If you aren’t sure, then ask yourself if other people seem to worry about it as much as you do. Ask yourself, too, how they would behave. Remind yourself to act moderately. You needn’t overdo it. There is no such thing as doing it perfectly. Overdoing it is the problem.
You used to criticize yourself a lot. It’s hard to remember why now, since you don’t do that anymore. You’re feeling good about yourself.
These can become can become your new thoughts.
There is no valid reason for criticizing yourself for disturbing thoughts or ritualistic behaviors. Those are just a part of OCD and you know that OCD is the enemy. You didn’t make up those strange thoughts; your brain chemistry was just tricking you. It may still be tricking you. Either way, why increase the harm that the OCD has done, or is doing, by criticizing yourself for it?
You never really believed the rituals were banishing the thoughts altogether. They were just a habit you developed before you knew what else to do with your recurring and disturbing thoughts. Maybe you haven’t broken the habit yet, but you will. Whether you’ve learned yet to cope without the rituals or not, self-criticism for compulsive behavior is counter-productive.
Put OCD in its place. OCD is not you and you are not OCD. You have many strengths, as everyone does. You have certain talents, skills, aspirations, knowledge and positive personality characteristics. OCD, on the other hand, is just a physiological disorder.
Do this exercise: Get out a piece of paper and a pen. Then, across the top, write, “talents,” “skills,” “ aspirations,” “ knowledge” and “positive personality characteristics.” Under each, write at least three descriptions that apply to you. If you can’t think of three, remember that even wanting a skill, knowledge about something, or a characteristic, is a strength. As an example, “Want to learn to play the piano,” can go under “skills.”
The next step is to use your strengths. If it’s a want, pursue it. If it’s an existing strength, figure out where you want to apply it and do it. Then, give yourself credit. You’ll deserve it.
When you get a compliment, thank the person who gave it to you. Accept that you deserve it.
At the end of each day, ask yourself what you did right that day. Explain how you did it right, to yourself. Tell yourself how well you did. If you think it might help, keep a journal and write out what you did well that day each evening before you go to bed. You’ll have plenty of things to write down, since you are becoming so busy with doing the things you want to do to live your life well.
Most depression is amenable to anti-depressants, so when you have taken them for at least a couple of weeks, you should feel noticeably better. If you don’t, tell the doctor and try another one. Not all of them work for everyone: It’s often a matter of finding the one that works for the individual. Anti-depressants take time to work. Don’t be discouraged when they don’t work right away. If there is a side effect when taking an antidepressant, be sure to tell the doctor this too. A medication adjustment or a new medication can frequently work. Sometimes, it takes up to several adjustments and medication trials, but don’t give up. You life is worth fighting for.
In addition to medications, everything mentioned here about taking control of your life and changing your self-talk from negative to positive can help with depression. Vigorous exercise is also very helpful for it. Serotonin, the chemical that’s related to the OCD mentioned earlier here, is also related to depression. You can increase serotonin in your body through exercise, thereby relieving some or all of your depression.
Having depression often leads a person to avoiding other people. People with OCD often stay away from others too, usually because they don’t want other people to notice their ritualistic behaviors. Sometimes, people with OCD don’t socialize because of the nature of their obsessive thoughts; As an example, if an individual has an exaggerated fear of germs, he or she may be afraid of contact with others. Both OCD and depression tend to be causes of social isolation.
The answer is to be around other people. It may be necessary to do this a little at a time and increase contact gradually, so as not to become overwhelmed or over-anxious. For some people, having a guest is a big step. Developing a new friendship or romance, or renewing an old one, is a definite success. The importance of developing a network of friendships is well-recognized by researchers as important to both mental and physical health. Your network can include supportive family members too.
Ruminations about the obsessive thoughts are common in OCD. The person is likely to think about possible causes, what to do to stop the thoughts and try to talk himself out of the thoughts over and over again. She may spend inordinate amounts of time thinking about where the blame lies for the thoughts and various ways of avoiding the thoughts. The person may also ruminate about the rituals; how to stop them, whether they are the best way to decrease the anxiety, why they work to some degree; why they don’t work completely and how to change, increase or decrease them to better stop the anxiety. In mental health parlance, repetitive thoughts without a productive solution are called ruminations. A person may be said to be ruminating or tending to ruminate. In everyday language, this might be referred to as over-thinking, dwelling too much on certain thoughts, or to use an old saying, chewing on an old bone.
Realizing that the ruminations aren’t helpful and are stealing precious time you could be spending on enjoying your life or managing it well is a first step toward overcoming them. Learning to distract oneself with positive thoughts, set and meet short timeframes for reaching final conclusions about the thoughts you’re ruminating on and performing productive activities towards life enhancement goals can help you cope with the tendency. A SSRI (selective serotonin reuptake inhibitor), usually prescribed for OCD, often helps decrease ruminations. Daily exercise may also help lessen ruminations.
If you tend to ruminate out loud with another person or persons, they will eventually tire of it when you won’t take their advice to let it go or make a decision about your worries. In time, you’ll find they won’t listen to it. They don’t want to feel as anxious as you do and will tune you out. When you don’t take their advice, they’re likely to feel annoyed. You’ll leave them with no choice but to stop listening. You may discover they’re unwilling to listen even when you have a legitimate concern and want their input or just a listening ear. It can drive a wedge between you and a person, or people, you care about that will permeate the relationship and may destroy it sooner or later.
Ambivalence can be a very frustrating condition if it’s frequent. Frequent ambivalence is also related to low serotonin levels, or at least to some brain dysfunction. It is so often part of both depression and OCD. A SSRI (selective serotonin reuptake inhibitor) may help with the ambivalence too. You may find that you can decrease this tendency even further by, again, only allowing a short timeframe for making decisions. Although this sounds easy, it’s often very difficult to do this, and will probably be especially difficult without the antidepressant to help.
As mentioned earlier, perfectionism is frequently one of the characteristics of OCD. This is a part of the rigid thinking that accompanies OCD. Consciously let go of the idea that you or your actions can be perfect. They can’t. Discard the rigid ideas involving perfectionism as they occur. Picture yourself taking the thought in your hands and throwing it into the trash can with a happy flourish each time you have one of these ideas.
In the same manner, discard all thoughts that include the words, phrases, and any derivatives, that are rigid in nature, such as; should, must and can’t. You can replace these thoughts with words and phrases like; I choose, I can, and I want to. Committing to something you choose, can and/or want is healthy. It means you living your life aside of the OCD. Using inflexible rules for your thoughts and behaviors is unhealthy. That’s a part of OCD and isn’t working for you.
If you have OCD, you’ve been avoiding anxiety and the situations that cause you anxiety by compulsively performing rituals or hoarding. If you only have the obsessions, you may be avoiding anxiety and situations that make you anxious too. Whichever is the case for you, the thoughts themselves may be a way to avoid anxiety and anxiety-producing events and circumstances. In addition to therapy and an SSRI, a small dosage of antipsychotic medication may be prescribed and may help you with this, but you also have some choices about other ways to handle your avoidance.
One way is to become conscious of when you are avoiding something, recognize that you are feeling anxious and then do it to the degree you can manage to. You can do it for a short while or take steps towards it until you reach the point that you don’t believe you can handle any greater anxiety. As an example, let’s say you become anxious when you have to leave your home. In this case, you might have customarily found a reason not to or performed a ritual that eased your anxiety enough to leave, like checking all the windows and doors several times. You can just leave and go to your appointment, but chances are high that you’ll feel the compulsion to do your checking ritual if you have compulsions. If you don’t have a compulsion, but just the obsessions, you might normally call and cancel the appointment or find another way to avoid going.
Instead, this time, you can choose to tell yourself why you want to go to the appointment. You can estimate how long the appointment will take, add some time, and then tell yourself you’ll leave when that time is up. Then, you can do that. You can also practice leaving beforehand and traveling a little further towards the place of the appointment each time. You might choose to practice with a friend by simulating your leaving for the appointment and staying there for as long as it takes to complete what needs to be accomplished there. You can also visualize it in your mind.
The point is to stop avoiding what you fear and what you fear will make you feel anxious, even if it means just a little more practice or actually facing it each time.
Control is a central issue for people with OCD. Although you are sometimes rational about your compulsions, the idea that you must perform them to become anxiety-free enough to control the anxiety for a short while is magical thinking. Magical thinking is a term used in the mental health field for an irrational and wishful belief. Your compulsions are meant to control anxiety. This propensity for needing to feel in control is often expressed in other ways too.
Rigidity is a form of control. You may insist on exact timeliness from others. You might always do your bills on the same date or day each week or month, and even at the same time. You may eat dinner at exactly six o’clock each day. You may become upset when things don’t go exactly as you planned or expected.
The tendency to try to control is often a self-defeating characteristic, mainly because you can’t control everything all of the time and probably not even the things you think are most important all the time. Trying to do so is setting yourself up for distress. Trying to control can also jeopardize your relationships if you expect to control any other person or they have a part in making your expectations come true. The efforts at control can multiply and leave you with even less time for healthy pursuits.
The opposite of control is to let go. When you aren’t anxious, or involved with obsessing or your compulsions, you can rationally think through what to let go. By increasingly letting go of the unnecessary rules you’ve made for yourself and others, determining that you will relax and allow uncertainty where you haven’t been doing so and living in the moment, you may be able to liberate yourself from the pointless exertion and frustration of trying to control life. You’re likely to have better relationships too.
10) Quality of life
Your quality of life is at stake in the fight against OCD. In fact, it’s the whole point of the battle. Do some serious thinking about what you ideally want from life. Decide on some long-term life goals for yourself. What do you want your life to be like in a year, two years and five years? How will you get there? What will you do this week towards those goals, and what will you do next week, next month and next year? Make up your mind on what you will really follow through on. Set some target dates for starting on those and some deadlines for those steps. Determine when you’ll reach your goals. Then, do it in leaps and bounds, or small steps, as you find you are able. You’ll gradually develop a life of quality for yourself.
You can do it
You can overcome or learn to manage your OCD. Challenge pessimistic thoughts about your chances and learn, as millions of other have, to live a satisfying life with or without the OCD. It won’t always be a good life, since no one’s is always good, but there will be more good times than bad.
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© Copyright 2008 by Jolyn Wells-Moran, PhD, MSW. All Rights Reserved. Permission to publish granted to GoodTherapy.org.
The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the preceding article can be directed to the author or posted as a comment below.