THE PROBLEM OF OCD
Obsessive Compulsive Spectrum Disorders (OCSD) including OCD, Asperger’s Disorder, Tourette’s Disorder, Hypochondriasis, Compulsive Hoarding, Trichotillomania, and Body Dysmorphic Disorder are chronic and often severely handicapping neuropsychological problems. Studies suggest OCD itself is in part genetically hard-wired into the brain (specifically the cortical-thalamic-striatal pathway within the basal ganglia) at birth, and its activation and expression can be affected by personality factors, life stress, immune system changes, hormonal fluctuations, weather, diet and many other factors. For most patients a variety of lifestyle changes and treatment interventions are necessary in order to reduce intrusive obsessive thinking and compulsive behavior as well as heal the depression which often accompanies OCD. We can then move on to restoring self-care, relationships and healthy lifestyle patterns
Without taking the risk of exposure to feared situations it is impossible for any of us with OCD to really progress in the healing process. However, when we do so – as noted above - brain imagery studies have shown us there is actual functional and structural healing which takes place in the cortical-thalamic-striatal region of the brain, something that is impossible to produce through any other method - including medication. Even if we have thousands of triggers for our OCD, because all of those triggers come from the brain, when we focus on one mastering one ritual through behavior therapy this heals the brain. This brain change that radiates out to ALL the rituals, weakening them (since ALL of them come from the same brain). Thus, some triggering situations will simply fade “on their own” with the result that, in the end, we do not have to deal with all our symptoms!
In general in order to master OCD we are confronted with two tasks (1) Creating behavioral exercises (usually along with a coach or counselor) designed to master the OCD and , (2) Developing our ability to confront and refuse to go along with OCDs demands as we run into them during daily life. In our first main task we must design and carry out exercises which allow us to get close to a feared experience, thought or situation. We then move on to habituate to the resulting anxiety by refusing to act out the rituals which we would normally use to dissipate the anxiety. In other words we come into contact with the thought, situation, person, or object we fear and remain in contact with thefeared stimulus long enough for the brain to habituate to the stimulus. This feels much like jumping in a cold lake of water and staying in the water long enough for the body to become accustomed to it. Brain imagery studies have shown that by using this procedure we can not only change the biochemical functioning of the brain, but also to some extent regrow new neural pathwaysaround the OCD!
This therapeutic process is called Exposure and Response Prevention (or ERP). When conducting ERP we utilize the Five Principles of ERP-CBT outlined in the box on this page to carefully construct ERP exercises which are both tolerable to the person and effective in causing habituation to the feared stimulus. In counseling ERP is often rounded out by the inclusion of other specialized exercises such as the Over-Valued Ideation (OVI) Exercise, Attention Training and the Multisensory Massed Imaginal Exposure (MSMIE) Exercise which are discussed elsewhere in OCD Recovery Center material. Let’s discuss in detail the 5 PRINCIPLES for developing - ERP / CBT exercises.
PART ONE: THE 5 PRINCIPLES FOR DEVELOPING
ERP / CBT EXERCISES
PRINCIPLE I: SAFETY / TRUST
When we first develop an OCD fighting exercise a measure of trust is essential. Paradoxically, this is often also the time when, thanks to the lies of the OCD, our trust is at its lowest ebb. We must work hard to overcome our fear and develop trust. Primarily trust that the exercises our ERP/CBT counselor is giving us are safe, but also trust in a higher power, the universe, destiny, or life itself. The well-know “Serenity Prayer” exemplifies this Key: “Grant me the serenity to accept the things I cannot change, the courage to change the things I can and the wisdom to know the difference.” We must develop trust that we cannot control everything (actually most things) in life.
Compulsive rituals, on the other hand, are designed to try to control what cannot be controlled. Yes, one may choose to brush one’s teeth in order to prevent cavities, but repeatedly placing our toothbrush in the holder seven or fifty-seven times will not prevent AIDS. So, while riding out the anxiety arising from ERP, the OCD sufferer is encouraged to again and again remember to let go of what cannot and should not be controlled.
In regards to designing ERP exercises, your counselor is charged with the responsibility of keeping you safe. It is your counselor’s job to design exercise that do not exceed what would be expected of the average person. ERP exercises should not cause harm, or panic (though they may cause fear of harm!)
PRINCIPLE II: INTENSITY OF EXPOSURE
Trusting in our ERP/CBT counselor, and trusting ourselves to let go of our attempts to control the universe, we begin creating Exposure and Response Prevention exercises. As we do so, the first essential element we must include is a manageable level of challenge. In any OCD fighting exercise it is important to make the experience of the stimulus (e.g. the level of anxiety it generates) manageable. Most OCD sufferers have a variety of compulsive behaviors they perform on a daily basis. Some, if stopped, would result in overwhelmingly intense anxiety leading to panic and an increase in future compulsive rituals. Other rituals carry with them only very mild anxiety and can be fairly easily eliminated without undue stress. In choosing which rituals to confront it is wise to make a list of all rituals and then rate them from highest (“100”) to lowest (“0”) in terms of the anxiety that would be generated if the behavior were stopped. Then rituals achieving a rating of 25-75 are selected for ERP/CBT.
If we stray outside this 25-75 anxiety ranger we run the risk of: triggering panic, being unable to do the exercise, being unable to resist neutralizing anxiety caused by the exposure, and reinforcement of target obsession. It is better to choose an exercise that fosters less anxiety and is manageable without performing a compulsion than choose a more difficult ERP exercise and later give in and neutralize the anxiety. In order to adjust an experience to fit within the 25-75 range we can: (1) Change the choice of target we are working on or (2) Change how target is experienced by (a) Adding or removing mediators (e.g. wearing gloves), (b) Adding or subtracting anxiety reduction techniques, (c) Adding or subtracting reassurance or modeling, (d) Increasing or decreasing duration of exposure or physical distance.
For example, we might choose to modify the strength of the stimulus/situation. For instance, one could spend only a few minutes by a trash can instead of an hour, or wear gloves while pumping gas, or ask someone to do the behavior first. All of these are “mediators” which will titrate the exposure to a manageable range – much as medication is titrated so that the patient will not get too much or too little. This allows us to hit the “therapeutic window” at which the exposure does the most good without overwhelming the individual.
PRINCIPLE III: NEUTRALIZATION / RESPONSE PREVENTION
Once a ritual is selected and we refuse to perform the behavior (or thought) in spite of the urgings of the OCD, a surge of anxiety will be experienced. The brain has sent an (erroneous) alarm message and we have refused to respond! As far as the brain is concerned a state of emergency exists and it will “warn” you by sending anxiety signals throughout your mind and body. It is crucial to remember that these anxiety signals will always recede if not acted upon - the anxiety will always go down! Often it will dissipate within 15 to 20 minutes, but even if it continues into the following day it will go down! But only if we resist the compulsive ritual our brain is demanding. This is what is referred to as “resisting neutralizing”.
Basically we are refusing the OCD’s commands not once but twice. We refuse to do the initial compulsive behavior (checking the stove) and then we stand our ground in spite of the anxiety we feel and refuse to perform a compulsive neutralizing behavior (calling our spouse to ask them to check to stove). This process takes immense strength, but does get easier as time goes on and then eventually results in more and more compulsions being resisted.
People with OCD are generally above average in intelligence. We will therefore have both primary and secondary rituals for relieving anxiety. For example, we can wait for long periods of time before performing a compulsion so that we can fool ourselves into believing it is not connected to the initial stimulus exposure. Also, neutralizing strategies can be very, very subtle such as a blink, a head shake or thinking about a color. It is essential to realize what neutralizing strategies are being employed and to stop them. Neutralizing strategies will always short-circuit the treatment process if allowed to continue.
Anxiety checks allow us to monitor our anxiety level, see that it is indeed dissipating, and helps us to view the process in a more detached, clinical way – seeing the OCD for what it is, an error message from our brain. We must simply allow the anxiety to be present like energy passing through the body and do “anxiety checks” every 5 minutes. Observing the anxiety level decreasing in this way provides strong encouragement. .
Persist in refusing the ritual until the anxiety dissipates – however long this may take. Once the anxiety does begin to reduce it is essential to avoid the temptation to perform another ritual to “un-do” the exposure. Like aerobic exercise, which must be done for a certain length of time in order to have cardiovascular benefits, one’s anxiety level must have decreased by at least 50% before any positive benefits will accrue. It is tempting to refuse a ritual initially, but then go ahead and do it in a little while. This will only provide the OCD with what is known as “intermittent reinforcement” – a pattern certain to encourage the OCD to continue generating demands for new rituals. It helps greatly for the patient to take note of their anxiety level (0-100) every ten minutes or so along the way. Observing the anxiety level decreasing.g provides strong encouragement to continue to refuse rituals.
It is important that we maintain awareness of the anxiety by doing “anxiety checks” every five minutes until the anxiety has dropped by 50% from its initial strength. At that point the individual can go on about their daily activities without needing to maintain awareness of the anxiety. It is important to remember that anxiety may show itself in thoughts, feelings, physical reactions and, or behavior. Each individual will be unique in their pattern of anxiety reactions and it may help to identify one’s specific anxiety symptoms prior to engaging in ERP.
In this Principle also slogans, reminders and sayings such as “Oh Really”, “Flavor Of The Day”, Questions will also tend to short circuit the OCD. Saying things like “Thanks For Sharing”, “I don’t know”, or “Whatever” in the face of an OCD situation are extremely helpful. By leaving things uncertain we short-circuit the OCDs desire for absolute certainty and perfect safety. They help us to break the illusion the OCD creates that it is real and must be obeyed. Slogans remind us of the truth – OCD ALWAYS LIES!”
PRINCIPLE VI: SATURATION / HABITUATION
PRINCIPLE V. DURATION / HABITUATION
I once had the pleasure of working with a woman from Belgium who was obsessing about gasoline. Once a month she would bravely drive to the gas station and, in a state or tremendous panic, pump a full tank of gas. She then drove home and washed and scrubbed her body the remainder of the day. She was being tremendously brave, but her OCD was getting worse. One of the first things she and I did together was to have her touch a cotton swab on the gas can her husband kept in the garage and touch the swab lightly on one wall in each room of her house. Her OCD began to get rapidly better.
The principles at play here are those of saturation and duration. In order to create change in the brain we need to expose ourselves to the feared stimulus more than just once a month – in fact quite regularly! This is similar to medication – one dose of an antibiotic will not (usually) be enough. We must take the medicine on a regular basis and we must allow it to saturate the infected areas of our bodies. Our woman from Belgium got better because her brain was continually exposed to the gasoline at a manageable level so that she did not feel an uncontrollable urge to neutralize the anxiety with a washing ritual. Saturation of the environment with the stimulus for an extended duration cause the brain to heal and build pathways around the “damaged” OCD circuitry.
PART II: THE 4 KEYS FOR MASTERING OCD EPISODES (OR CONDUCTING ERP-CBT EXERCISES)
Once we have designed ERP-CBT exercises using the Five Principles our second main task is to learn how to master the OCD as it shows up during daily life. It is one thing to participate in a controlled exercise designed by a counselor to habituate ourselves to our fears, but quite another to refuse to give in to OCD “hits” that pop up – sometimes by the thousands – during the course of an average day! We must learn to negotiate our way through the often confusing and usually terrifying act of turning to face one’s obsessions while not succumbing to the urge to neutralize the anxiety through rituals or compulsions?
Here again, having a structured plan of action (or non-action) is essential. Frequently OCD sufferers will report that car accidents, hurricanes, earthquakes, public speaking, near plane-crashes and even armed combat and the like are not nearly as terrifying as confronting an obsession. This is because obsessions are generated directly from the brain! If we were to put a wire into the amygdala area of your brain and turn on some electricity we can generate much more fear than we can asking you to walk through a mind field or jump out of an airplane. It is precisely because it is so difficult to refuse to perform obsessive-compulsive rituals that it is essential to have a set procedure for doing so. At the OCD Recovery Center we usea specific 5 Key procedure for walking through the anxiety mine-field Self-Directed Exposure and Response Prevention (SD-ERP) These 5 Keys, if followed closely, will take an OCD sufferer step-by-step through the flames of anxiety that can seem so intense.
It is recommended that the 5 Keys be applied consistently day after day until they become second nature. The Keys have been given short labels to make them easier to remember them in practice.
KEY I: IDENTIFY
Our first task when confronted with a situation where our OCD is stimulated is to recognize that the urge to perform the obsessive ritual is in reality a faulty brain message not a real danger. We must concentrate our awareness on what’s happening - on the obsession / ritual - long enough to truly and clearly see and feel it as just OCD and not a “real” danger or issue. Several strategies can help with this: (1) Asking “what would a person without OCD do in this situation, (2) Slowing down and focusing strongly on the real world around you – NOT on the thoughts going on inside you. (This is known in Zen Buddhism as “bare attention.”), (3) Placing trust in a higher power, the universe, destiny, or life itself – realizing that rituals / compulsive behaviors are not a way to control outcomes in life, (4) Repeating to oneself slogans, sayings, or reminders (such as “You can’t put out fire with gasoline!”) that pull your attention out of the “OCD Quandary” (“Should I?”, “Shouldn’t I?”, “What if?”) to see that OCD is not real, there is no decision to make, you are not in danger, and life just is what it is.
Regarding slogans, sayings and reminders, it is particularly helpful to write down or record these so that they are outside of our own thoughts. Since OCD happens inside our mind seeing, reading or hearing the truth about OCD from outside ourselves (even if it is we who created the media) is very powerful.
In Key 1 we remind ourselves that the urge to perform an obsessive ritual is in reality a faulty brain message. Obsessions are thoughts that have gotten stuck in our awareness. If we could eliminate our thoughts (or even control them) we could theoretically eliminate OCD! This in turn advises us that our job is not to “get the OCD right”. Instead we must learn NOT to “dance” with the OCD. Dancing with OCD only leads us to become more and more stuck – like a fly on flypaper, or a camel in quicksand. We must refuse to play OCD’s thought games, or figure it out, or do what it tells us to do.
As with so many things related to OCD, the success of Key 1 relies on brain science! There are two directions we can turn our mind’s focus – inward or outward. When we are listening to OCD we are focusing inward. The more we pay attention to the OCD – trying to get all our rituals “right” the more we tune into our inner world – and the more the OCD part of our brain heats up. When we focus outside ourselves on our environment, and our bodies, we shift our consciousness to an entirely different area of the brain – a non-OCD area! It is this critical shift from inward to outward that breaks the spell of the OCD. We realize that we have OCD we are not the OCD!
KEY 2: DEFY
With a clear awareness that “this is just OCD” it becomes easier (though still often immensely difficult) to refuse to do what the OCD is asking us to do, think, or say. In Key 2 we simply “just move on” with whatever activity we were planning to do when the OCD distracted us. We do NOT do the “protective” ritual that the OCD is telling us so strongly we must do!
This is the simplest step, but by no means the easiest. I worked once with a combat hardened Airborne Ranger who reported he would rather be in battle “any day” than have to deal with OCD. Why? Because the fear our brain can generate goes far beyond any fear that situations and circumstances outside of us can stimulate. Fear, after all, is a chemical response in the brain.
There is a saying that we do not find our courage before we do a frightening thing – we find it because we did the difficult thing! So it is that we must work very hard to defy the OCD – to refuse to believe that what it is telling us – in order to find our courage. There is no ritual that must be done to prevent whatever catastrophe the OCD promises will befall us or our loved ones. It is all just an illusion and this will become apparent after we defy the OCD! The anxiety will be great, but it will not last. You are doing the right thing to resist OCD and there will be a benefit down the line as you brain begins to heal and recover.
KEY 3: UNMASK
Our next task is to mentally unmask the OCD – seeing it for what it really is - an erroneous alarm message from the brain. This is similar to what we did in Key 1, but we are now further along in the sequence of dealing with the “hit” from the OCD. As we feel the anxiety resulting from our defiance of the OCD the heightened anxiety tends to re-cloud our thinking - OCD’s lies become even more believable! Punching holes in this believability is our most essential task. We must use all our mental focus to distinguish between the inner OCD thoughts and the reality of outside experience while continuing with life. This is the MOST import of all the Keys because this is where the real brain change we are looking for happens!
It is not enough to feel the anxiety that comes from defying the OCD. We must also see that the obsessional thought which is so strong right now is just a lie – just a distorted alarm message from our brain. We can counter this error message by forcing ourselves to separate from the OCD, disbelieve it, and see through it. If we can do these two tasks together - (1) Feel the anxiety and (2) See there is no reason for the anxiety - our brains will be changing. As we unmask the OCD we will be trimming the “OCD weeds” from our brain garden and allowing the wild flowers of free-will to grow once more.
Often this means actually stopping all activity and concentrating one’s awareness on what’s happening long enough to truly and clearly see and feel it is just OCD - and not a “real” danger or issue. Armed with this awareness it is then possible to be aware both mentally and experientially that the compulsion is not a real “choice”, but rather an expression of the obsessive compulsive disorder. Various slogans and other forms of self-talk can be used to achieve this end.
KEY 4: RESIST
In Key 4 we work hard to resist the desire to neutralize the anxiety using our typical strategies - ritual behaviors prescribed to us by the OCD. We must hold out, refusing to act compulsively to relieve our anxiety, while waiting for that anxiety to gradually fade and our minds to clear from the illusions created by the OCD. Again, normally the anxiety generated by and OCD “hit” dissipates in 15-20 minutes. This is why it is essential to tell ourselves “I will not give in and do the ritual for at least 15-20 minutes. I can do the ritual later if I just can’t take the pressure.” Likely after 15 minutes you will be looking back at the OCD hit and saying, “Yup, that was just another error message from my brain just like all those other times. I’m sure glad it didn’t go along with it.”
It is useful to note that even if one gives in to an OCD ritual it is still possible to make it a “win” by clearly acknowledging that one has had a “slip” and that the OCD has won a round, but that nothing real has been accomplished or lost. A helpful statement here would be “I gave in to the OCD and its meaningless!” (instead of “I protected myself, or accomplished something by doing the OCD compulsion.”) Also, if one gives in to a ritual another healthy choice would be to find another similar challenge to do right away so that the OCD doesn’t feel it has had a victory.
One caveat here - conducting self-directed cognitive-behavioral therapy is very, very difficult without a guide, mentor, counselor, recovery buddy or some other type of individual who can assist. OCD tends to be self-perpetuating and it is extremely difficult to (1) separate from the obsessional thoughts and (2) stay consistent day after day with the ERP exercises. Like charging directly into enemy fire, recovery from OCD is a fairly straightforward process – but the courage it takes to get started and stay the course is often immense. Working with a “recover buddy” or coach makes the OCD easier to handle and keeps us on track.
There are many other helpful approaches to living with OCD. However, without ERP/CBT self-help measures (e.g. learning relaxation training, aerobic exercise, taking vacations) will likely eventually be overwhelmed by the compulsions and rituals.
There are, of course, many other aspects to OCD recovery which are discussed in other OCD Recovery Center articles (especially our article on Special Characteristics of OCD) such as increased needs for reassurance or symmetry, neuropsychological and physical differences, etc. Of particular note, OCD tends to increase our “something is wrong” feeling and this easily becomes a “something is wrong with me” feeling! We need to be gentle and kind with ourselves. We are trying hard to live with and get better from a horrible disorder.
OCD recovery is not simply confronting rituals and compulsions. Undertaking this courageous task leads to all kinds of positive downstream effects such as reduced depression, increased feelings of self-sufficiency and a reigniting of our spontaneity and free-will. The freedom gained through ERP is a precious gift that only a recovering OCD sufferer can appreciate fully and the self-love which develops along the way is worth the effort.
Special Note: Any discussion which has the words “steps” and “OCD” in proximity to one another must offer a deep and heartfelt thank-you to Jeffery Schwartz, MD who developed the initial Four Step Model of self-directed cognitive behavioral therapy. Dr. Schwartz is indeed an intellectual “giant” and those of us who follow are fortunate to stand on his shoulders.
Christian R. Komor, Psy.D. is a Clinical Psychologist who combines 15 years of clinical experience treating Obsessive Compulsive (OC) Spectrum disorders with discoveries from his personal recovery from OCD. Dr. Komor is the author of Obsessive Compulsive Disorders: A Comprehensive Program for Recovery (2001), The Obsessive Compulsive’s Meditation Book (2000), OCD and Other Gods (2000), and The Power of Being (1992) and EarthSpirit! Dr. Komor leads seminars nationally for professionals on optimal treatment of obsessive compulsive disorders. He is the founder of the OCD Recovery Center of America based in Grand Rapids, Michigan which offers both standard outpatient and intensive outpatient treatment programs for the many OC disorders. For more information, or to order books, tapes or materials visit The OCD Recovery Center or Komor Earth Images
Copyright 2014 by Christian R. Komor, Psy.D. All rights reserved.