Kathleen Kawamura, PhD Clinical Psychologist
Kathleen Kawamura, PhDClinical Psychologist 

Obsessive Compulsive Disorder

***This section is provided as an example of the thorough conceptualizations that are available for the specific anxiety disorders (social anxiety, panic disorder, obsessive compulsive disorder, generalized anxiety disorder). I chose to use OCD as an example as it is commonly misunderstood and information regarding the disorder is an important component of treatment.***

 

OCD is no longer classified as an anxiety disorder, nevertheless anxiety is a primary component of the disorder. Disgust and guilt are other emotions that may be experienced. Severe distress is accompanied by a cycle of obsessions and compulsions that characterize OCD.

 

Many people can relate to superstitious beliefs or to being "obsessive" about cleanliness or safety, but OCD is when these beliefs and behaviors begin to interfere with one's life in that it takes up more than an hour each day, causes a significant amount of distress, and impairs functioning in relationships, at school, at work, or in daily life.

 

OBSESSIONS

 

Obsessions are intrusive, unwanted thoughts, images, or impulses that trigger intense distress. Obsessions are not the same as everyday worries in that oftentimes obsessions have little or no basis in terms of realistic probabilities of harm. Common obsessions include:

 

  • Fears of contamination
  • Fears of harming oneself or others
  • Unwanted sexual thoughts
  • Immoral thoughts/religious concerns
  • Hyperawareness of bodily sensations
  • Relationship doubts
  • The need to have things "just right"

 

COMPULSIONS 

 

Compulsions are routines or rituals that are meant to prevent or reduce the distress that comes from the obsessions, and unlike gambling or drinking, compulsions are not experienced as pleasurable but rather torturous and time consuming. Common compulsions include:

 

  • Washing and cleaning
  • Checking
  • Repeating
  • Arranging
  • Mental Compulsions (e.g., counting, praying, cancelling thoughts, mental review)
  • Reassurance seeking

 

The Obsessive Concerns Checklist provides a thorough list of common obsessions while the Compulsive Activities Checklist provides a thorough list of common compulsions. 

 

The Yale-Brown Obsessive Compulsive Scale is also a list of common obsessions and compulsions along with questions to assess the severity of symptoms. 

 

These measures are not meant to diagnose OCD but can give an understanding of the typical thoughts and behaviors that may be causing distress.

 

UNWANTED, INTRUSIVE THOUGHTS
 

The obsessions listed on the Obsessive Concerns Checklist are not specific to those with OCD, and in fact, studies have shown that most people in the general population acknowledge having had similar unwanted, intrusive thoughts at some point in their lives.

 

Thought Generator:

 

An explanation for why we have these spontaneous thoughts is that our brains are equipped with an ability to generate new ideas, which enables us as humans to create art, produce original solutions, or invent something new. It comes from systems in the brain that act collectively as a “thought generator.”

 

Some of these thoughts may be truly original ideas or they could be random connections to something we had heard, seen, or imagined. Sometimes thoughts may pop up just because there is a part of us that believes we should NOT think these thoughts.

 

The OCD Spotlight:

 

Findings have shown over and over that there are few differences between those with OCD and those without regarding the content of unwanted, intrusive thoughts.

 

The difference is that for those who do not suffer from OCD, unwanted, intrusive thoughts are usually evaluated as merely strange or perhaps disturbing, but no matter how repulsive or horrific the thoughts may be, they are experienced as just thoughts and thus not particularly problematic.

 

The thoughts may come uninvited, but for the most part, these fringe thoughts have to be accessed purposefully such as for a creative writing project or when recalling a horror movie. Either way, these thoughts are usually not processed any further and are quickly forgotten.

 

For those who struggle with OCD, these same thoughts present as loud, intense, and persistent making them difficult to ignore. It is as if the thoughts are being lit up by a bright spotlight. It is important to recognize that the intensity of the thought does not necessarily make the thought more important, just as the loudness of a voice does not necessarily make a message more meaningful nor does the size of a font make a message more real, though they do make the messages very difficult to ignore.

 

Danger detection system:

 

Threatening thoughts that are brightly lit are more likely to be interpreted by the parts of our brains dedicated to self-preservation. This “danger detection system” is designed to anticipate, notice, and react to danger in a way to protect us from harm. This is the role of anxiety.


Two important parts of our brains that are involved in the “danger detection system” are the amygdala and the cortex. The amygdala is part of our primitive brains and is involved in processing emotions. It learns from experience and can be conditioned to react rapidly and automatically to what it perceives as danger.

 

The amygdala is like an alarm in that it is the part of the brain responsible for setting off the fight or flight response. Once the fight or flight response has been initiated, it takes time for the effects to dissipate.

 

See the section on Understanding Anxiety for a more thorough description of the fight or flight response and of neurological explanations of anxiety.

 

The amygdala learns through experience that certain thoughts trigger a fight or flight response, and each time this pairing occurs, the connection between thought and fear response becomes stronger. A saying is, "Neurons that fire together, wire together," meaning that the pathway between certain thoughts and the fight or flight response becomes tread in so deeply that eventually a thought can automatically trigger a physiological response.

 

The cortex, or the “thinking brain,” has the ability to dampen or sustain the amygdala’s alarm system depending on how it evaluates the situation. Thoughts that are interpreted as important, meaningful, or dangerous sustain the alarm system of the amygdala which then creates feelings of anxiety, dread, disgust, or an urgent need to get rid of it.

 

On the other hand, if the cortex sends a message to your amygdala that you are not in danger, the alarm will stop and the physiological symptoms of the fight or flight response will slowly dissipate on its own.

 

The problem with OCD is that after the initial obsession and associated fear response, there are often follow up statements such as “Thinking these thoughts is just as bad as acting out on them,” “If I’m feeling anxious, this must mean something bad is going to happen,” “These thoughts mean I am a horrible person,” or “I need to know with certainty or else something terrible will happen.” These thoughts then work to sustain the alarm system thus maintaining the fight or flight response.

 

For those who suffer from OCD, the “thought generator” may be highly active, the “spotlight” may be brightly lit, and the “danger detection system” may be very sensitive so that these systems interact and react as if their lives are in imminent danger. These systems may be related to inheritable traits in brain chemistry or brain circuitry that are made even more sensitive by stress, fatigue, illness, or excessive drinking or marijuana use.

 

IIMPORTANCE PLACED ON THOUGHTS/COGNITIVE APPRAISALS

 

When thoughts are appraised as being dangerous, immoral, disgusting, or meaningful, then the amygdala is triggered and a surge of anxiety, disgust, doubt, or discomfort follows. The more important the thought, the greater the distress and the more likely the obsession.

 

Therefore, it is not surprising that harm obsessions often occur with gentle people, sexual obsessions occur with highly moral people, religious obsessions occur with religious people, and obsessions with mistakes occur with perfectionistic people.

 

Some appraisals have to do with the thought’s content whereas other appraisals have to do with the presence of the thought. Either interpretation can lead to significant distress.

 

The goal of therapy is not to argue with or change the thoughts but rather changing the perspective on the thoughts and learning to see them as thoughts that are happening and not necessarily threats.  

 

MALADAPTIVE BELIEFS

 

There appear to be common themes underlying these appraisals in those who suffer from OCD. These beliefs tend to be rigid and absolute and contribute to the development and maintenance of OCD. These beliefs can be categorized as: 

  • Inflated responsibility - the belief that one can prevent horribly negative outcomes
  • Over-importance of thoughts - a thought is considered very important just because it exists, usually because having the thought means the feared event is more likely to happen or having the thought is just as bad as the action
  • Importance of controlling one's thoughts - complete control of thoughts is believed to be possible and necessary
  • Overestimation of threats - the probability and severity of harm are over-exaggerated
  • Intolerance of uncertainty - absolute certainty is necessary and coping with unpredictability and ambiguity causes much distress
  • Perfectionism - the belief that it is possible and necessary to not make any mistakes, that there are perfect solutions, and that making a minor mistake will have catastrophic consequences

 

The Obsessional Beliefs Questionnaire is used to assess common beliefs about thoughts in those who suffer from OCD. 

 

COPING STRATEGIES in OCD

 

When importance is attached to the presence of a thought or the content of the thought, then the thought is experienced as dangerous, disgusting, or unbearable. The fight or flight response may also be triggered.

 

The natural protective response to these distressing emotions and feelings is a desire to get rid of the thought, control the thought, or put the fear to rest in some way.

 

Thought suppression, neutralization strategies, and avoidance behaviors are the most common coping strategies that contribute to the cycle of obsessive thoughts and compulsive behaviors.

 

In the beginning, these coping behaviors lead to a decrease in distress, and because there is some relief, these behaviors become reinforced and are more likely to occur the next time the distressing thought or feelings are experienced.

 

Eventually these behaviors become habits that feel automatic and uncontrollable. Unfortunately, in the long run, attempts to suppress, neutralize, or avoid the thoughts or feelings of fear:

 

  • make the thoughts more likely to return
  • lead to MORE anxiety
  • do not work as well in relieving distress for any significant amount of time
  • do not allow baseline levels of anxiety to return to original levels
  • do not directly address the source of the problem
  • create more problems in day-to-day living (emotional distress, relationship problems, professional consequences, health problems)

 

An increase in thoughts and fear likely occur because the efforts put into getting rid of or avoiding the thought or situation tells the brain that these thoughts or situations are important, meaningful, and dangerous. The brain then becomes fearful and alert, making it more likely for the thoughts to return, for baselines levels of anxiety to be higher, and for the anxious response to be greater. This then strengthens the feeling that these thoughts need to be controlled.

 

Because avoidant strategies do not directly address the source of the problem (the OCD), the cycle continues to spiral out of control creating additional problems.

 

Ultimately, the obsession and the anxiety are not the greatest problem, but rather it is the desire to avoid anxious feelings completely that becomes the biggest hurdle to living a full and meaningful life.

 

THOUGHT SUPPRESSION: The Paradoxical Effect

 

One common reaction to this surge of anxiety that accompanies the obsessive thought is to try to NOT think of the thought. The problem with this strategy is that there is a paradoxical effect where the more you try NOT to think of a thought, the more the thought will come to mind.

 

For example, if you were asked to close your eyes and try to think of polar bears for 2 minutes, you will find that various thoughts and images of polar bears cross through our mind, sometimes disappearing and reappearing outside of your control.

 

Now, if you try to NOT think of polar bears for the next 2 minutes, you will find that your thoughts are interrupted by thoughts or images of polar bears. If you were asked to do it for 20 minutes and pay $100 each time the thought or image occurred, the stakes become higher, and the task becomes impossible at worst, exhausting at best.

 

The reality is that we have little mental control over the thoughts that come into our mind and the more we attempt to control it, the worse the problem becomes.  

 

NEUTRALIZATION STRATEGIES: Compulsions

 

Compulsions are external behaviors or mental rituals that are also attempts to neutralize, avoid, or remove the distress caused by the obsessions. Because compulsions do provide some immediate relief, the behaviors become reinforced, meaning they are more likely to happen again in the future in response to distress.

 

The problem with compulsions is that because of the polar bear effect described above, any attempts to remove or suppress the thoughts strengthens the importance placed on the thoughts making the thoughts more likely to return. This strategy, which seemed logical at first, becomes part of the problem.

 

Unfortunately, the relief provided by engaging in compulsions is often temporary and partial. The anxiety does not quite return to baseline, and when the thoughts returns, anxiety often returns with greater intensity. It is as if engaging in compulsions, confirms to the brain that the obsessions are dangerous or important and must be taken very seriously and with immediate action.

 

Another consequence is that compulsions, which are essentially responses to false alarms, do not allow the brain to learn that the thoughts or situations are not as dangerous as they seem and do not require immediate attention and also that the anxiety will eventually decrease all on its own and can be managed. 

 

On the other hand, if there is no avoidance, there is no partial decrease in anxiety, but there is a natural habituation curve where the anxiety first increases rapidly, plateaus, and then slowly decreases. This is the natural curve of the anxious response.

 

With neutralization, there is never a chance to learn that the anxiety will decrease all on its own and that the feared consequence does not happen.

 

AVOIDANCE

 

Another common coping strategy for dealing with fear is avoidance. Avoidance can include a wide variety of triggers such as situations, people, objects, information, physical sensations, emotional states, or thoughts.

 

The problem is that efforts to avoid the trigger places greater importance on the thoughts that are being avoided. In addition, with avoidance, there is no learning that the thoughts are thoughts that you can learn to handle and that the anxiety will decrease eventually on its own.

 

Also, avoidance leads to constant scanning of the environment for any other triggers. The list of triggers to detect and avoid grows longer and life becomes more restrictive.

 

REASSURANCE SEEKING

 

Another common coping strategy in OCD is reassurance seeking. Like the other strategies discussed, reassurance seeking often lowers anxiety only temporarily but enough that the urge for reassurance gets stronger each time around.

 

Reassurance is often specific to a time and situation and thus any changes to the situation or any small doubt about the reassurance or the source of reassurance will require another round of reassurance seeking.

 

The problem is that the reassurance that is being sought is 100% certainty regarding a situation, and because this is not possible, there is a continuous need for reassurance.

 

Reassurance seeking can include asking someone about the obsession, researching the obsession, confessing to try to get reassurance, and self-reassurance such as mentally reviewing actions for reassurance that nothing bad happened.

 

Like the other avoidant strategies, reassurance seeking increases the importance placed on the thought because of the attention given to the thought which then makes the thought more likely to occur.

 

Usually the need for reassurance increases over time where each new doubt requires reassurance and any answers that are given only generates more doubts.

 

As with the other strategies discussed, reassurance seeking does not allow learning to occur that the fears are not likely and that the anxiety will decrease on its own.

 

OCD CONCEPTUALIZATION

 

Trigger....Thoughts (Obsessions)....Appraisal....Anxiety Surge....Compulsions....Anxiety Relief....Obsessions  (repeat)

 

The development and maintenance of OCD is believed to occur as follows: a thought occurs (with or without a trigger), importance is placed on the thought (faulty appraisal based on maladaptive belief system), this appraisal leads to a surge of anxiety (false alarm), this distress leads to efforts to remove the distress (compulsions), and the compulsions and appraisals make it more likely for the thoughts to reoccur and become obsessions.

 

With each cycle, the frequency and intensity of the thoughts increase, which leads to more catastrophic appraisals, which leads to higher levels of anxiety, and which leads to more rigorous use of compulsions. This is the way in which the obsessive compulsive cycle can become debilitating.

                                          

The parts of this model that are not under voluntary control are the obsessions and the surges of anxiety. These aspects are involuntary in that spontaneous or disturbing thoughts can occur with all people and a surge of anxiety is a normal reaction to the perception of danger.

 

The parts that are potentially under voluntary control are the importance placed on the thoughts and the strategies used to deal with the distress (the appraisal and the compulsions). In the beginning, it may seem as if these components are also outside of voluntary control but it is just that they have become highly automatic.

 

Shifting out of thoughts and behaviors that have become automatic takes time and effort but eventually can be replaced by a new, automatic way of dealing with obsessions.

 

TREATING THE OCD BRAIN

 

There is a significant amount of information that suggests that OCD is a brain-related disorder that makes it difficult for the mind to let go of thoughts or urges. Dysfunction in certain brain structures (orbitofrontal cortex, basal ganglia) and brain systems (cingulo-opercular network) have been implicated in the development of OCD.

 

These brain structures and systems are thought to be responsible for generating normal impulses and urges with a built-in brake mechanism to stop these thoughts and urges. In OCD, it seems that the brain is overactive in generating thoughts, images, and impulses, and furthermore, like an itch that won't go away, the mechanism that tells us, "Your hands are clean, you can stop washing," or "The stove is turned off you can go to work now," does not function properly and does not get triggered.

 

Some people will ask, "If OCD is a brain-related disorder, then is medication the only treatment?" The answer is a pretty solid, "No."  Studies have consistently found that cognitive-behavioral therapy can lead to significant reductions in OCD-related symptoms, similar to improvements with medications. More compelling is the evidence through brain scans that show that improvements with cognitive-behavioral therapy lead to similar brain changes as improvements with medications.

 

Psychotherapy can teach you new ways of approaching OCD while medications can help facilitate that process, making it easier to interrupt and redirect OCD thoughts and tolerate the discomfort of change. Therapy can be seen as a tool to help you decide what thoughts and behaviors to "grow," while medications "fertilize" and promote this growth. Once new patterns are established, these changes can be long lasting, even when medications are discontinued.

 

TREATMENT STRATEGIES

 

Education: It is important to have a strong understanding of the model of OCD as described above. This information will be used to help understand obsessive thoughts and appraisals that lead to distress. A more realistic, less catastrophic explanation for the obsessions can help manage the distress related to the obsessions.

 

It is also important to understand the treatment rationale as aspects of treatment can be challenging and distressing, and understanding WHY these strategies are being used can help make these uncomfortable feelings more tolerable.

 

Self-monitoring: It is important to understand your own unique obsessions, appraisals, compulsions, and avoidance behaviors. Self-monitoring can help identify patterns in your distress and all this information will help develop a specific treatment plan. 

 

Mindfulness: Analyzing, arguing with, judging, reassuring, or explaining the thoughts tend to entangle the mind with the obsessions by adding importance to the thoughts, which then strengthens the obsession. For this reason, standard cognitive therapy techniques of challenging the fear often fuel the obsessions and increase the anxiety. This is because the OCD is seeking reassurance and unfortunately thoughts cannot be proven with absolute certainty to be untrue or safe.

 

Mindfulness can be used to train the mind to not react immediately to the worrisome thoughts by pushing them away or by debating them and instead acknowledging them, recognizing them as OCD, and accepting them.

 

For example, learning to respond with, "I am having thoughts about being uncertainty and harm," is a much different experience than, "I didn't check the stove before I left. If I don't go back and check, the house will burn down and I'll be responsible."

 

Mindfulness can be seen as the opposite of thought suppression, avoidance, and neutralizing compulsions. Accepting the obsessions does not mean wanting them or enjoying them, but rather acknowledging that they exist in the present moment and sitting with them without adding to the pain and distress that is already a part of the experience. Mindfulness is used to train the mind to observe the distress and also patiently sit with the urge to engage in a compulsion. 

 

Cognitive techniques:

 

Rather than engage with the content of the obsessions, the most effective cognitive therapy tools are to recognize that OCD related distortions in thinking may be occurring and without engaging with the content of the thoughts.  Cognitive therapy techniques can also be used to guide thoughts away from the urge to engage in the compulsive response. Maladaptive beliefs can also be explored to see ways in which they may be contributing to the maintenance of OCD.

 

Exposure and response prevention (ERP)

 

The primary treatment approach for OCD is called Exposure and Response Prevention.

 

Exposure means approaching in a graduated and controlled manner thoughts, images, objects, or situations that trigger obsessions. 

 

Response prevention refers to allowing the anxiety to naturally and slowly subside on its own rather than engaging in a compulsive response that only strengthens the OCD. Response prevention allows for learning how to tolerate feelings of discomfort and distress without engaging in compulsions.

 

The belief is that a moderate level of anxiety is necessary to turn on the anxiety system and prime it for change. By continuously triggering the obsession and the fear and not engaging in a compulsion, the brain eventually habituates to the obsession allowing the fear response to naturally dissipate.

 

With repeated exposure, the brain responds with less anxiety each time until the trigger no longer leads to intense distress. Exposures are thus opportunities to rewire the brain by teaching it that feared consequences do not necessarily occur and that the ability to cope is stronger than once believed.

 

ERP can be the most challenging component of therapy but it is often times the most effective. Trying to think differently about obsessions does not seem to be as effective as experiencing it for yourself. It seems as if the part of the brain that is responsible for the fear response learns best through experience.

To make the process more tolerable, education, self-monitoring, and cognitive techniques are used to prepare for ERP.

FINDING A THERAPIST

Many therapists claim to use cognitive behavioral therapy (CBT) but are in fact using aspects of CBT incorporated into their style of talk therapy. Other therapists may be familiar with the idea of Exposure and Response Prevention (ERP) in the treatment for OCD but may not be well-versed in the complicated nature of the disorder and its treatment.

 

For the most effective treatment, it is important to find a therapist who has training and experience specifically in ERP for OCD.

 

The International OCD Foundation listed the following questions to ask to ensure you are getting a qualified OCD-treatment professional:  

  • What techniques do you use to treat OCD?
    • If the therapist is vague or does not mention CBT or ERP, use caution.
  • Do you use ERP to treat OCD?
    • Be cautious of therapists who say they use CBT but won’t be more specific.
  • What is your training and background in treating OCD?
    • If the therapist went to a CBT psychology graduate program or did a post-doctoral fellowship in CBT, that is a good sign. Another positive is if a therapist says they are a member of the International OCD Foundation (IOCDF) or the Association of Behavioral and Cognitive Therapists (ABCT). Also, look for therapists who say they have attended specialized workshops or trainings offered by the IOCDF like the Behavior Therapy Institute (BTTI) or Annual OCD Conference.
  • How much of your practice currently involves anxiety disorders?
    • A good answer would be over 25%
  • Do you feel that you have been effective in your treatment of OCD?
    • There answer should be an unqualified, “Yes.”
  • What is your attitude towards medication in the treatment of OCD?
    • If they are negative about medication, this is a bad sign. While not for everyone, medication can be a very effective treatment for OCD.
  • Are you willing to leave your office if needed to do behavior therapy?
    • It is sometimes necessary to go out of the office to do effective ERP.

 

MORE INFORMATION

 

The International OCD Foundation provides thorough information on OCD, its causes, and its treatments.

 

 

READINGS AND REFERENCES

 

Anxiety and Avoidance: A Universal Treatment for Anxiety, Panic, and Fear (2103) by Michael Tompkins

Calming Your Anxious Mind: How Mindfulness and Compassion Can Free You from Anxiety, Fear, and Panic (2007) by Jeffrey Brantley and Jon Kabat-Zinn

Cognitive and Behavioral Methods for Obsessive-Compulsive Disorder in Brief Treatment and Crisis Intervention (2003) by Maureen L. Whittal and Melanie L. O’Neill

The Cognitive Behavioral Treatment of Obsessions: A Treatment Manual. Unpublished treatment manual.

Cognitive Treatment of Obsessions in Brief Treatment and Crisis Intervention (2003) by Sabine Wilhelm

Cognitive Behavioral Treatment of Obsessive-Compulsive Disorders: A Commentary in Cognitive and Behavioral Practice (2003) by David A. Clark

The Mindfulness Workbook for OCD: A Guide to Overcoming Obsessions and Compulsions Using Mindfulness and Cognitive Behavioral Techniques (2013) by Jon Hershfield and Tom Corboy

Overcoming Unwanted Intrusive Thoughts (2017) by Sally Winston and Martin Seif

Rewire Your Anxious Brain: How to Use the Neuroscience of Fear to End Anxiety, Panic, and Worry (2015) by Catherine Pittman and Elizabeth M. Karle

Treating your OCD with Exposure and Response (Ritual) Prevention (2012) by Edna B. Foa and Tracey K. Lichner