Obsessive-Compulsive Disorder (OCD) is characterised by the presence of obsessions and associated compulsions. Obsessions can be described as recurrent, intrusive and unwanted thoughts, images or impulses, whereas compulsions are characterised as repeated behaviours or mental actions performed in response to obsessions to reduce distress. There are many types of obsessional thoughts that can present in people with OCD. Some examples of these include thoughts about harming someone else, thoughts about germs, thoughts about the meaning of life, losing things, forgetting things, being worried that something bad might happen, worries about your health, thoughts about things not being or feeling “right”, thoughts about your sexuality or other personally unacceptable thoughts.
Interestingly, every single person in the general population experiences intrusive thoughts several times per day. However, for most people, these thoughts can go unnoticed because they are fleeting and there is no further meaning attached to the thoughts. People with OCD, however, take an extra step with these intrusive thoughts by attaching meaning to them. This then leads to distress, which then leads to a ritual and/or a compulsion being performed to alleviate the distress. Unfortunately, the rituals and compulsions are almost like an ‘addiction’, where after a period of time, no amount of ritual and compulsion feels satisfying enough to reduce the intensity of the distress. The performance of rituals and compulsions, although reducing anxiety in the short-term, actually maintains anxiety and distress in the long-term. Consequently, this results in spending a lot of time engaging in rituals and compulsions, which takes away your ability to concentrate and engage in everyday tasks associated with life (e.g., school, work, relationships, etc.).
How Do You ‘Get’ OCD?
There is no one known cause for OCD. Some theories have shown that OCD characteristics (such as perfectionism or rigidity) run in families, suggesting that genetics can play a role in developing OCD. Other theories suggest that the meaning people attach to intrusive thoughts teaches them to fear their triggers. Some say that the anxiety and doubt you experience is what causes you to do a ritual or compulsion, because you’re trying to feel better or to get rid of the unhelpful feelings. What this action does is reinforce the importance of intrusive thoughts by further increasing the chance of the thoughts reoccurring. This is because the fear associated with the intrusive thoughts compels you to ‘learn’ to react to the intrusive thoughts, and therefore take them seriously when engaging in compulsions. This also means that the more you engage in the rituals and compulsions, the stronger the links in your mind become, and the more likely it is that you will keep engaging in the behaviour.
Will I Ever ‘Get Better’?
Many people who have engaged in early treatment have improved. Importantly, the aim of treatment is not to ‘get rid of’ intrusive thoughts. Since the brain’s job as an organ is to think (amongst other things), it remains safe to say that we cannot control what ‘pops’ into our minds. What therapy aims to do is to reduce the fear and worry that is associated with intrusive thoughts. Compulsions and avoidance, on the other hand, can be eliminated and/or significantly reduced. In the long run, it is hoped that you will be able to accept that intrusive thoughts are normal and experienced by everyone in the general population. This does not mean that you like them or want them. It means that we build tolerance to uncertainty. You just see the thoughts for what they are, just thoughts. You also can’t forget the thoughts because of the way the brain works, but they can become a distant memory over time.
Exposure and Response Prevention (ERP) is undoubtedly the most effective treatment to reduce symptoms in people with OCD. In general, ERP involves direct contact with what you are scared of for many times each day without any performance of compulsions. It’s a simple formula but likely one of the most difficult and challenging forms of treatment to apply because OCD does a very good job of convincing us that what we’re experiencing is real and must be avoided at all costs.
Exposure and Response Prevention (ERP)
The choice of target for an ERP task is made based on the level of difficulty. You should begin with “easier” tasks and work your way up to more difficult ones. In general, exposure therapy is successful when the tasks undertaken are performed in a slow, gradual manner with consistent monitoring of progress made before, during, and after ERP.
It remains preferable for no compulsion to be performed in response to an exposure task. However, this is sometimes not possible, particularly when lengthy and/or repeated compulsions are performed to neutralise obsessional anxiety. Examples here include repetitive hand washing, repeated checking of stove, electrical equipment, doors, windows and locks. In all these circumstances, whilst the preference is for zero compulsions, alteration of the pre-existing compulsive ritual or routine can be helpful. Any alteration of any part of the compulsion, including the order of performance, speed of action and the number of times performed will act, in some ways, as an exposure task and will provoke anxiety that can be tolerated and eventually demonstrate habituation. It remains important that these situations are only steps towards the final goal of the complete abolition of all compulsions.
Sometimes merely delaying the performance of the compulsion can act as a useful first step. For situations where you might be highly fearful of the non-performance of compulsions, the delay phase can alter your perceptions and highlight that immediate performance of compulsions is not that important. This method, however, has only limited value, particularly if the treatment does not proceed to complete abolition of compulsions. Similarly, the use of distraction and performance of other behaviours or even physical prevention of the performance rituals can be helpful in certain circumstances but raises the possibility of reducing the effect of the exposure by distracting you from your feared thought and the fear of consequence. This remains a difficult area and regular discussion between you and your therapist needs to continue to make sure that you are not using distraction or other behaviours to avoid the anxiety associated with the exposure.
Types of Exposure Tasks:
Below you will find a list of some ideas of exposure tasks to get your creative juices flowing. Be mindful that reading this list alone can be triggering so you may have to practice sitting with discomfort while reading this list.
· Watching short triggering videos on YouTube (i.e. videos of people vomiting, videos of car accidents for ‘hit and run’ type fears, etc.)
· Reading newspaper articles that contain triggering content such as stories about paedophiles, murders, AIDS/HIV, car accidents, murder-suicides, fires, floods, death/obituaries, etc.
· Listening to podcasts about triggering content such as medical podcasts (for health anxiety triggers), true crime podcasts or podcasts, etc.
· Watching triggering television shows
· Watching triggering movies (e.g. Girl Interrupted for those who experience fear of losing control or going ‘crazy’)
· Sitting on the floor in the lounge room with hands palm down on the ground while watching TV
· Touching door handles
· Cooking dinner with loved ones around
· Leaving the knife block in plain sight of others
· Creating a loop tape with triggering words (e.g. a voice memo where you read out a list of words and listen to it on repeat for a set amount of time per day)
· Reading a novel with triggering material
· Sending an email without checking it for mistakes
· Leaving the house and reducing the number of checks performed before leaving
· Reducing the amount of time spent in the shower or messing up the order of the ritual when in the shower
· Reducing the steps in a ritual when performing one so it’s ‘not quite right’
· Interrupting counting compulsions and coming back to the present moment
· Following accounts on social media with triggering content such as ‘mummy bloggers’, a children’s clothing store, or a cooking store, etc
· Using the trolley at a supermarket
· Delaying compulsions by longer time intervals until resistance can occur
· Touching a bleach cleaning bottle in the aisle at the supermarket
· Not holding your breath when walking outside for fear of inhaling ‘pollution’ from cars
· Going for a walk around the block without scanning the ground – keeping the eye gaze at the level of the horizon – noticing what you can see, hear, feel, touch, etc.
· Opening the door by using the door handle with the whole hand, not just fingers
· Lighting a candle in the house and walking away from it for a few minutes at a time
· Writing down the statement – ‘I want my mum to die in a car crash on the way home from work’, and other such statements for harm related thoughts.
· Not taking a photo of the stove (or other items/objects) to have evidence that it’s safe, off, etc.
· Resisting the urge to carry disinfectant wipes and sanitiser on your person
· Resisting the urge to go to the GP to check somatic complaints (e.g. checking for signs of illness)
· Watching vomit videos on YouTube (for emetophobia)
· Taking the bins out without washing hands
· Doing the laundry without washing hands in between each step
· Not cuffing up pants so that ‘germs’ can be collected off the ground onto pants
· Not separating clothing from inside to outside clothes – and similarly not having clean and unclean zones in the house
· Doing opposite action to movement or impulse related intrusive thoughts
ERP is by no means an easy form of therapy to engage in. If you would like support with ERP in the treatment of OCD please give our team a call on (03) 9882-8874) to arrange a time with one of our trained team members.
This blog was written and prepared by Dr Celin Gelgec - Clinical Psychologist and Director at MWG.