In the United States, around 1.6% of adults will meet the criteria for obsessive compulsive disorder (OCD) in their lifetimes. Obsessions are intrusive thoughts that cause distress. Compulsions are repetitive actions a person feels they must do. Someone with OCD has both obsessions and compulsions that interfere with everyday life.
Although obsessive-compulsive behaviors can be debilitating, the condition is treatable. People with OCD can receive help through therapy.
Psychotherapy for OCD usually includes both cognitive behavioral therapy and exposure and response prevention (ERP). If an individual has multiple obsessions, therapy typically focuses on one theme at a time.
In ERP, the person in treatment confronts their obsession. They then avoid acting on the compulsion. The therapist helps the individual work through the resulting anxiety. For example, someone with a symmetry obsession may be asked to roll one sleeve up, then refrain from evening out the other sleeve.
Cognitive behavioral techniques can help put obsessions into perspective. In therapy, a person can learn to recognize unrealistic and distorted thoughts. They may also develop tools to cope with distress without resorting to compulsions.
At first, the therapist only asks the person to delay their compulsions for a short period. As therapy progresses, the gap between exposure and response grows. Ideally, as a person grows desensitized to the obsession, their urge to do compulsions will decrease.
Sometimes people have intrusive thoughts about forbidden acts. Obsessions could include yelling slurs, hitting a child, or cheating on a spouse. The thought may go against a social taboo, or it may break one’s personal code of ethics.
People with “forbidden” obsessions often feel guilt for having such thoughts. They may worry about losing control or being secretly “bad.” But they are unlikely to do the feared actions, even unconsciously. When people with OCD do act on impulse, they often engage in body-focused repetitive behaviors (BFRBs) such as hair pulling.
People with OCD are not any more dangerous than the general public. But obsessions can be stressful in themselves. ERP can help many individuals address their symptoms.
In some cases, a person may be unable to confront their fear directly. Someone worried about poisoning their family cannot ethically act out that scenario. These cases may be better treated through other forms of exposure therapy.
In imaginal exposure, a person imagines the feared situation in detail. A therapist may use audio tapes or short stories as prompts. In virtual reality exposure, a person might play a simulation to act out forbidden impulses on characters who can’t feel pain.
Exposure therapy is often helpful for treating pure obsessional OCD. With practice, a person can see “proof” they will not act out if they ignore their compulsions. Mindfulness techniques can also help a person cope with unwanted thoughts.
Like adults, children with obsessions and compulsions are often treated with ERP and cognitive therapy. Since OCD triggers are often present in daily life, a therapist may ask children to practice coping strategies at home. Caregivers may need to help kids with these assignments.
For example, one parent may help the child write a story about their forbidden thoughts. Another may monitor a child to make sure they wash their hands only once before dinner. Even giving sympathy after a hard day can help.
Here are some strategies parents can use to support a child with OCD:
- Be a cheerleader: Resisting compulsions can take a lot of willpower. Improvement often comes in small steps. Praise can motivate children to continue their progress.
- Avoid blame: It can be frustrating to watch your child’s symptoms improve one day, then regress the next. But criticism is unlikely to motivate your child. In fact, the added stress can make symptoms worse.
- Avoid accommodation: Children with OCD often turn to adults to soothe their doubts. For instance, a child may ask, “Did I turn off the faucet? Are you sure? Can you check if I really did it?” Although you may want to reassure your child, doing so can encourage compulsive behavior. It is okay to let a child be uncertain.
- Fight OCD, not each other: Remind your child that they are not their symptoms. Encourage your child to see treatment as a cooperative battle rather than a chore.
- Make a contract: It is often easier to negotiate rules before a crisis sets in. Discuss with your child how strictly you will enforce rules, when to make exceptions, and how often you will hold “family check-ins.”
- Spend quality time together: Not every conversation needs to be about OCD. Talking about other topics can help shift a child’s focus away from their obsessions.
Some people with OCD take medication in tandem with therapy. A psychiatrist will likely prescribe a selective serotonin reuptake inhibitor (SSRI). These medications help the neurotransmitter serotonin travel through the brain more easily.
These medications may take 8-12 weeks to begin working. A person with OCD will likely need a higher dose than someone taking these drugs for depression. Common side effects include nausea, drowsiness, and weight changes, among others.
Experts recommend consulting one's care provider before abandoning a medication. If a person suddenly stops taking a drug, they may experience withdrawal effects. In other words, their OCD symptoms may temporarily get worse. It is generally safest to wean oneself off the drug under professional supervision.
- Adolescent boy teased for displaying obsessive-compulsive behaviors in school: Jason, 14, has been teased in school because he sits down and stands up over and over in class. Jason cannot explain his reasoning, only that he feels as if he must do so. His family takes him to therapy. The therapist recognizes obsessive-compulsive behaviors and investigates Jason’s environment for stressors. The therapist learns Jason's father has an anger problem and refers the father to anger management therapy. This lessens, but does not eliminate, Jason's obsessive-compulsive behaviors. The family chooses not to place Jason on medication due to potential side effects. In therapy, Jason learns relaxation techniques and develops problem-solving skills. He also learns methods to delay the unwanted behaviors so others are less likely to notice them. Jason continues in therapy as he approaches adulthood. Over time, the behaviors diminish and all but disappear.
- Chronic hand washing caused by anxiety: Rivka, 47, enters therapy seeking help for compulsive hand washing. From childhood until her 30s, she washed her hands every ten or fifteen minutes. When her first husband left her, she had to get a job where she no longer had constant access to a sink. Rivka was able to replace the hand-washing compulsion with counting, which she could do while working. Recently, the compulsion to wash her hands has returned. In therapy, she uncovers feelings of guilt and shame dating back to childhood. Rivka needs several months of therapy to work through those difficult feelings. She also accepts an anti-anxiety medication to take when her compulsions are at their worst. Therapy enables her to function reasonably well and to relax more often. Before long, the compulsion begins to subside, and she chooses to stop the medication. Though Rivka continues in therapy, she is able to reduce the frequency of her sessions.
Therapy is meant to be a place free of judgement. No matter which OCD symptoms you have, the rules on confidentiality still apply. A therapist cannot tell your spouse or your boss about your obsessions, regardless of what you are thinking about those people.
A therapist will not call the authorities simply because you have intrusive thoughts. Most people have unpleasant or unwanted impulses on occasion. Very few intend to act on those urges. To be considered a threat, you must have a desire and a plan to harm others (or yourself).
If a therapist specializes in OCD, chances are they have encountered your symptoms before. No matter how terrible a thought may seem, someone else has likely had it. You do not need to let shame or guilt prevent you from getting treatment.
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