Treatment for Obsessive-Compulsive Disorder (OCD)

What is OCD?

Obsessions are thoughts, images, or urges that come to mind repeatedly and unintentionally. They are stubborn, intrusive, and unwanted, almost always producing anxiety and distress. In the case of OCD, the sufferer may attempt to ignore or suppress these thoughts, images, or urges or tries to neutralize them through other thoughts or actions, aka compulsions. Compulsions are repetitive behaviors like hand-washing or item ordering, or mental acts like counting or praying—in short, just about any activity that is designed to reduce the anxiety produced by the obsession. For those suffering from OCD, the compulsions (also called rituals) become excessive.

What isn’t OCD?

It is not obsessive to have occasional anxious thoughts about your fears or feel concern for the safety of loved ones. However, what characterizes obsession for OCD sufferers is  a demand for perfect certainty. You know how you can’t read people’s minds or predict the future, yet get along just fine? It is the same with certainty: you can’t ever achieve 100% certainty, but you can and do get along fine without it.

Similarly, compulsions do not include actions like harmless religious rituals, bedtime stories, or the like. Compulsive actions are characterized by their context: they are undertaken because the OCD sufferer is trying to neutralize or stop something bad from happening.

Example Scenario of OCD

Now that we have some understanding of what obsessions and compulsions are, let’s look at an example of an OCD cycle using a hypothetical character named Bill, who is anxious about contamination. Let’s say that Bill has experienced obsessions regarding fear of contamination to chemicals, and pesticides in particular, for about 3 years. 

Scenario: Bill opens the door to the bathroom at work with a tissue in his hand (to protect him from contamination) but thinks that he feels something wet come through the tissue. He looks at his hand and doesn’t see any moisture.

First Obsession: Bill thinks, “I don’t see anything, but what if it dried quickly after I got it on me and it’s still there, dry, and toxic?”

Second Obsession: Bill envisions himself getting sick and missing work, which may lead to getting fired or even dying!

Compulsion: Bill carefully takes 3 paper towels from the dispenser, which he uses to turn on the handle of the water faucet and then to squirt soap from a dispenser. He begins to feel his anxiety go down slowly as he washes his hands 5 time. He pays special and exhausting attention to what he believes is the affected area.

Aftermath: As he cautiously dries his hands, Bill thinks: “What if I didn’t get it all?” Although he tries to talk himself out of it with reassuring thoughts, he washes his hands five more times. Then he thinks, “What if I just spread it more?” Bill continues to cycle through these “what if” questions and washing his hands five times.

Analysis

Bill didn’t see any moisture on his hand and his logical mind said, “Move on,” but he didn’t. Why? The disorder is telling him that before he moves on he must be absolutely, perfectly certain of no toxin. This impossible desire for certainty causes him to doubt that what he senses is true—that there is no moisture on his hand.

Risk is a normal part of living even if we don’t want it. The only method any of us have for knowing is our best logical guess, which means we will always face some risk in life, however slight. People who don’t suffer from OCD would have an easier time moving on from the bathroom door scenario without requiring more evidence. They would have lived with what they considered a very small risk, but Bill is now anxious and stuck because his distorted thinking demands perfect certainty.

We all live with the low-probability risk of dying from a toxin we can’t see. Trying to find certainty that there is no risk will cause you to worry your life away. Bill’s distorted thinking tells him that it should be possible to avoid this risk completely, but the truth is that perfect certainty is not attainable, nor is it necessary.

Extrapolating from this low-probability risk, Bill sees an obsessive image of himself getting sick, missing work, perhaps getting fired, or dying (all negative predictions about the future)! At this point, Bill is very anxious, which sets the stage for his next move. Keep in mind that his perception is that he is in immediate, life-threatening danger and he must be certain that this is not true.

Following emotional reasoning (“If I am anxious, there must be a danger, so I must get rid of that danger”), Bill decides to wash his hands thoroughly. However, each time he finishes washing and drying his hands, he finds himself asking more “What if?” questions. It will never stop: demanding certainty is the engine of OCD. It will only keep asking, “What if?” and handing him another possible negative problem that will make him wash as a way to try to get certainty of no risk.

There is no perfect certainty

Bill will never become perfectly certain. Eventually, however, he will be forced to finally say, “This is good enough,” and walk away. He will walk away because he is too tired, embarrassed, or humiliated, and his hands are chapped and cracked. And still, he will not be perfectly certain. A person who does not have OCD would have walked away in the first place—this is what Bill will need to learn to do. Treatment for OCD, primarily through exposure and response prevention (E/RP) therapy, will help Bill learn to walk away and break the cycle of obsession and compulsion.

Types of Obsessions in OCD

The obsessions and compulsions of OCD sufferers can vary widely—if a suffer can think of something, they can also obsess about it. Some say that OCD is only limited by the imagination. However, below are a few common areas of obsessive concern:

*Note that the following lists are not exhaustive, so please check with an expert who specializes in the treatment of OCD if you have questions. Each person is unique, and so are the contents of an individual’s OCD.

• Contamination: Bodily fluids or waste, household chemicals, environmental chemicals, germs, dirt, garbage, radiation, particular places or people, certain thoughts, certain events.
• Harm to Self/Others: Losing control and harming others, losing control and harming self, causing harm to others/self through thoughts, negligence, or carelessness, doubt if you have harmed someone in the past.
• Aggression: Fear of harming self/others intentionally, fear of going crazy and harming others, fear of shouting or writing out embarrassing obscenities, fear of making obscene gestures, of having insulted or offended someone.
• Perfection: Questioning if you have told the truth perfectly, questioning if others have understood you perfectly, keeping your possessions in perfect order, wanting to have a perfect appearance.
• Sexual Obsessions: Fear of having forbidden perverse thoughts, images, or impulses, fear of acting out sexually or being sexually excited by children, fear of desiring or having sex with animals.
• Religious Obsessions: Fear of being sinful or blasphemous on purpose, fears of having acted sinfully, having undesirable thought about religious deities.
• Health and Body-Focused Obsessions: Believing that parts of your body are ugly or disfigured, asymmetry of parts of your body, fear of brain damage, fear of a serious undiagnosed illness.
• Neutral Obsessions: Excessive awareness of your own thoughts, counting for no special reason, bothered by certain sounds, words, or music, excessively aware of normal bodily functions like blinking, breathing, or heart beating.
• Magical Obsessions: Having bad luck, lucky/unlucky numbers, colors, or multiples of numbers.

Types of Compulsions in OCD

• Decontamination: Washing your hands or body repeatedly and excessively. Using gloves, paper, or some other item to touch or pick things up. Disinfecting yourself and your possessions or having others disinfect themselves. Changing or having others change clothes frequently in order to avoid contamination. Also, frequently avoiding touching others or things for fear of contamination.
• Perfectionism: Keeping your things perfectly neat and clean, not using newly purchased items for fear of messing them up, avoiding using rooms, closets, or anything storage space once it has been arranged perfectly, saying things perfectly.
• Checking: Checking locks, doors, windows, stoves, car doors, headlights, water faucets, electrical appliances, extinguished cigarettes, and matches. Repetitively praying or crossing oneself. Checking what you have read, columns of numbers, your memory, the item you think you may have left behind, or food for fear of contamination.
• Undoing: Repeating something with a good thought in it, rethinking thoughts, thinking thoughts in reverse, performing actions or movements in reverse, touching things in a special way.
• Mental Compulsions: Thinking thoughts in a specific or special way, knowing or learning everything on a specific topic, creating specific thoughts or images, checking memory for past harm to self/others.
• Counting: Counting while performing certain activities, repeating behaviors a certain number of times, performing behaviors odd or even numbers of times.
• Touching or Movements: Posing or gesturing in a certain way, move in specific ways while doing specific activities, tic or grimace in a special way, touch, tap or move your body in a certain fashion.
• Protective: Warning others repeatedly of potential harm or danger, confessing to having done things that may have caused harm to others, asking others repeatedly if things will turn out ok or will turn out well for you.
• Body-Focused Compulsions: Checking for imperfection or problems with your body in the mirror, checking your body for symmetry, cutting your hair for long periods of time to get it perfect. Frequently seeking medical consultations for possible illnesses, frequent self-exams, frequent reading on the internet about illnesses you fear that you have.
• Hoarding: Saving items simply because they belong to you or a loved one. Saving broken, irreparable or useless items. Experiencing an inability to throw out items due to fear of accidentally throwing away something important.

Prevalence and Treatment

It has been estimated that about 1 in 100 people suffer from OCD, and some estimates are as high as 1 in 40. If you go to a Phillies game attended by 40,000 people, that means about 400 attendees suffer from OCD—that’s a lot of people! If you are one of them, know that you are certainly not alone.

There is no need to label yourself either. We name the condition in order to productively talk about it, research it, and ultimately treat it effectively. However, suffering from and being diagnosed with OCD does not reflective everything you are and can be. OCD is treatable; you are not your OCD.

The American Medical Association (AMA) and the American Psychological Academy (APA) recommend Exposure/Response Prevention (E/RP) therapy as the first-line, psychological treatment of choice for OCD. OCD has been shown to respond best to a specialized CBT treatment primarily using E/RP.

Consult an expert

Harold P. Kirby is a nationally-recognized expert in the treatment of obsessive-compulsive disorder. Contact Harold at 610-517-3127 to schedule a consultation or appointment to discuss treatment for OCD. Harold provides telehealth treatment for clients in Philadelphia and the surrounding areas of Pennsylvania and New Jersey (Main Line, Montgomery County, Camden, Cherry Hill), as well as in the South Carolina Lowcountry (Hilton Head, Bluffton, Beaufort, Colleston County, Dorchester County, Berkeley County, Charleston).