CHAPTER
20

Managing OCD

In This Chapter

• Understanding obsessions and compulsions
• Learning to identify and overcome magical thinking
• Lessening your dependence on rituals
• Using behavior experiments to test the validity and need for your rituals

You think you forgot to turn off the stove and go back and check. You can’t leave the house without systematically checking that every window and door is locked. You spend hours organizing and reorganizing your bookshelves. Everyone has daily routines and double-checks things sometimes, but if you have obsessive compulsive disorder (OCD), these behaviors become obsessions and compulsions that take up time and interfere with your daily life. This chapter will help you understand the relationship between obsessions and compulsions and provide you with strategies to help lessen your dependence on rituals.

Understanding Obsessive Compulsive Disorder

Obsessive compulsive disorder (OCD) is an anxiety disorder characterized by obsessions and compulsions. Obsessions are intrusive and upsetting thoughts, images, or impulses that occur repeatedly in your mind. You feel powerless to control these thoughts. Compulsions are behaviors and rituals you feel you must complete. Compulsions are often repeated and done in an effort to relieve the obsessive thoughts.

For example, suppose you worry about germs; you are afraid you might touch someone or something and become ill. These thoughts overtake you and you must wash your hands. Until you are able to wash your hands, you don’t feel relief. In more severe cases of OCD you have a ritual, such as washing your hands five times. You perform this ritual to try to diminish the thoughts about germs; however, it probably only provides short-term relief.

IMAGINE THAT

Not all obsessions are accompanied by rituals. Some forms of OCD are known as “Pure O.” You may just experience the obsession part and hold on to the obsessions in your mind until you are exhausted or an external event resolves the problem.

Common obsessions include the following:

• Distressing religious or sacrilegious thoughts; for example, thoughts about joining a cult or worrying about religious prosecution for your sins.
• Intrusive thoughts of violent acts, such as having hurt someone in the past or thoughts about hurting someone in the future.
• Sexual thoughts or images; for example, worrying you are homosexual, have a sexually transmitted disease, or that you did something inappropriate.
• Constant worry about contamination from dirt, germs, bodily fluids, and other materials.
• Worry about throwing away something important or needing something you threw away; for example, hoarding newspapers, communications, tax papers, or clothing.
• Constantly worrying that you made a mistake.
• Worry that you have a disease.

Common rituals:

• Spending excessive time putting things in order to make them “right,” such as lining things up, making lists, or reorganizing files.
• Washing hands, kitchen counters, and bathrooms excessively.
• Repeated checking to make sure you completed a task; for example, turning off the oven, locking the door, or rereading communication.
• Mental rituals such as repeating words or phrases.
• Seeking reassurance or medical advice; for example, surfing the internet for medical diagnoses or repeatedly checking with friends and family to make sure things will turn out okay.

When you suffer from OCD, you become irritated or distressed when interrupted or prevented from performing your rituals. You might need to seek constant reassurance from your partner, friends, or family, wanting to be assured that nothing bad is going to happen, you don’t have a disease, and how you look is acceptable. If your obsessive thoughts are about violence, you might believe you are a terrible, evil person and your obsessions are causing others pain.

When you try to avoid your obsessive thoughts or resist completing compulsions, you end up giving in because it seems unbearable when you don’t. Your obsessions and compulsions take time out of your day; often several hours per day is spent on dealing with obsessive thoughts or carrying out rituals. OCD is a spectrum disorder, which means it ranges from mild to severe.

STOP AND THINK

Rituals do not need to be external or physical acts. Rituals are sometimes internalized, such as counting, going through a checklist in your mind, or creating an elaborate plan to overcome a disaster.

Some people who experience obsessions recognize that their beliefs are false and the need to complete their ritual is simply a way to alleviate their anxiety. This is the first goal in overcoming OCD.

Your Turn: Identify Your Triggers

Keep a log for several days to find if there are certain places or situations that trigger your obsessive thoughts. If you have many obsessive thoughts per day, write down between three and five each day rather than writing each individual obsession.

GIVE IT A TRY

Use the ladder technique described in Chapter 5. List your triggers in order from easiest to hardest. Start with working on overcoming the easiest trigger first and work your way up the ladder. If you try to face fears too quickly, you decrease the effectiveness of exposure exercises. Be sure to write a specific goal, such as using the shopping cart without antiseptic, as the top rung of your ladder.

This example includes obsessions about germs, but you might find you have several different obsessions, such as contamination, the need for exactness or evenness, or the fear of harming others because you aren’t careful enough. When you go through the other exercises in the chapter, choose one of your obsessions first. Once you have learned to manage that obsession, move on to another.

Thoughts Are Just Thoughts

It is impossible to avoid your thoughts. In CBT therapy for OCD, the goal is not necessarily to challenge your thoughts but rather learn to accept that the thoughts are there without attaching any validity and meaning to the thoughts. A thought is just a thought; it is when you attach a meaning that you react to it and likely to keep having the thought.

Your Turn: Thought Exposure

When you have OCD, your fear isn’t necessarily something physical; instead, you have obsessive thoughts. As with anxiety, exposure therapy works to lessen your obsessions. However, you can’t physically face your thoughts. Thought exposure involves writing down your obsessive thoughts, in detail.

Start by writing down your obsessive thoughts. Fill in as many details as you can. Write down how you feel and what you want to do.

For the next two weeks, write down the same obsessive thoughts. Your obsession might change slightly or it might remain relatively the same. Try not to use the same words every day.

Writing your obsessions might trigger additional obsessions or cause you to create more scenarios revolving around the same obsession. Don’t worry; this is normal. Keep writing about it every day. This exercise should desensitize you to your obsession. Over several weeks, you should notice the frequency of your obsession decrease.

Overcoming Magical Thinking

Many people with OCD have what is called the magical thinking phenomenon. This is when you believe that if you don’t complete your compulsions, something bad will happen and it will be your fault. You think that what you do, or don’t do, has a negative impact in your environment or the world. For example, your obsessive thoughts are about causing harm to another. You worry that if you don’t count and tap your hand on the wall 10 times, your grandparent will become ill.

DEFINITION

Magical thinking is when you believe that if you do something, or don’t do something, that it has an effect on your environment or on the world. For example, you might believe going through a certain good-bye ritual with your children each morning will keep them safe through the day.

Gathering evidence to disprove your obsession is a good way to combat magical thinking. The following is an example of how this works.

Obsession: I am contaminated. Germs make me sick or cause me to get a disease.

Compulsion: I need to wash my hands immediately after riding the subway.

Magical thinking: I will get a disease and spread germs to my children if I do not wash my hands as soon as I get off the subway.

Gathering evidence: Think back to a time you rode the subway but did not wash your hands for at least 15 minutes. Did you get sick? Did your children get sick? Did your prediction come true?

Practice by delaying completing your ritual. This challenges your belief that something is going to happen, or not happen, as a direct result of your compulsions.

As you continue working with your OCD, it is important to postpone completing your ritual without looking for evidence or challenging the thought. Doing this is considered a mental form of seeking reassurance.

Response Prevention

As you begin to accept that your obsessions cannot cause someone harm and are not a sign of what is going to happen in the future, you need to work on accepting the discomfort that comes from not carrying out your rituals. Rituals are often carried out in order to avoid a feeling of discomfort. You want it to relieve your anxiety. Lessening your dependence on completing rituals is called response prevention. It means to delay or ignore your need to complete the ritual.

Imagine you have a cold. You start obsessing that it is much more serious, that you have a serious disease. Your first thought is to surf the internet for reassurance that this is not a serious disease. This is your ritual. Start by waiting 15 minutes before giving in to your desire to search the web. When 15 minutes has passed, if you still have the urge to carry out the ritual, ask yourself, “Can I handle the discomfort for another 15 minutes?” Try to delay the ritual another 15 minutes. Keep doing this until you no longer have the urge or anxiety. In the beginning, it will be harder to not give in to the ritual, but eventually you will find that it’s easier to ignore the ritual. The more you resist your compulsion, the more your obsession will subside.

Behavioral Experiments

In Chapter 10 you learned how to create a new belief and then test its validity. This technique is helpful when trying to change obsessive thoughts.

Situation: You constantly seek reassurance from your partner about what you are wearing. You want to make sure your clothes are appropriate for work or an evening event. You don’t like to leave the house without first checking with him; when you do you spend the entire day self-conscious of your appearance.

Belief: I must check with my husband on my appearance before I leave the house.

Experiment: I will plan to get dressed and purposely leave for the store without asking him.

You get dressed, go to the store, and come back. Nothing terrible has happened. No one pointed at you and laughed. No one seemed to notice that you didn’t look perfect. No one seemed to care what you were wearing. You complete this experiment several times and have similar results. Sometimes people comment on how nice you look. Your experiment shows that you can get dressed and leave the house without first asking for reassurance on your appearance.

Do the same experiment when getting dressed for work or going out for the evening.

Let’s look at another example.

Situation: You have a fear of getting sick from drinking from a public water fountain. You always carry water with you so you don’t have to use a water fountain. You become agitated if your children ask to get a drink from the water fountain when you are at the mall.

Belief: My children or I will get sick if we use a water fountain.

Experiment: Drink from the water fountain.

You go to the mall and take a drink from the water fountain. You watch over the next several days but you don’t get sick. You repeat the experiment several times over the next couple weeks, using different water fountains. You still don’t get sick. Your obsession slowly starts to disappear.

STOP AND THINK

When creating a behavior experiment, decide how you are going to know whether your prediction comes true. Vague statements such as “to see what happens” aren’t going to give you the information to disprove your original belief. Use specific statements, such as “If no one gets sick within three days of drinking a water fountain,” or “If no one at work states something critical about my outfit.”

You can also use the opposite technique when completing experiments by increasing the frequency of completing rituals. This helps in associating the ritual with the unpleasant obsessions. For example, suppose you are worried that your house is going to burn down. You repeatedly check to make sure the stove is turned off. You believe that checking the stove helps relieve the anxiety. Try the following experiment.

Day 1: Keep a log and mark down each time you check the stove. Rate the intensity and duration of your anxiety before and after you check the stove.

Day 2: Increase how often you check the stove. If you did so 15 times the day before, check it 25 times today. Continue to rate your level and duration of anxiety.

If you notice an increase in your anxiety on Day 2, checking the stove is not helping your anxiety; in fact, it is making your anxiety worse. From this experiment you can tell your ritual is part of the problem, not part of the solution. Eliminating the ritual will reduce your anxiety.

In order to reap the benefits of behavior experiments, the same experiment needs to be repeated several times. Each time you repeat it you reinforce your new belief. Once you have mastered an experiment where you feel no anxiety, move on to another experiment.

Exposure Therapy

You learned a CBT technique involving exposure to your fears in Chapter 17. You can use this same technique to help relieve your fear of certain situations when you have OCD.

Start by making a list of situations that provoke your intrusive thoughts or compulsions, such as shaking someone’s hand. The more you confront the fear and learn nothing happens, the less control your fear has over you. The anxiety surrounding shaking someone’s hand will slowly diminish.

GIVE IT A TRY

Sometimes you are not able to face your perceived fears because they are not an object or situation. Suppose you check your stove repeatedly because you are afraid your house is going to burn down. You can’t face the fear of your house burning down. Instead you can use imagery. Create detailed images of the disaster you fear will happen. In this example, you would imagine your house burning down and resist the urge to check the stove.

Rank the situations on your list from mild to severe, with those that cause only mild anxiety on the top of your list. Begin your exposure exercises with these and work your way down your list to those that cause greater anxiety. Stay with each situation until you feel comfortable and don’t need to perform any rituals to lessen your anxiety.

Begin your exposure gradually. For example, if you are anxious about shaking someone’s hand, start by shaking the hands of friends or relatives without washing your hands after. Work your way up to shaking the hand of a stranger. It is important to resist your urge to perform any rituals after exposure. Your rituals reinforce your fears; therefore, you can’t move past those fears without ending the ritual.

Each time you shake someone’s hand, rate your anxiety level. In the beginning, you might rate it at 100 percent, but as you practice, you find your anxiety levels decrease. Use this technique in conjunction with your behavioral experiments, noting in your log that you did not get sick after shaking someone’s hand. This helps you reevaluate your beliefs and challenge their validity.

Tips for Reducing Rituals

There are some thinking styles that contribute to OCD. By working on changing your thinking, you can help to reduce the obsessions and your need for rituals.

Manage stress. Managing OCD is not easy. You might have some days when you face your fears and feel you made progress, and then the next day your fears resurface, causing you to feel hopeless. Stress often causes symptoms of OCD to increase. Create a plan to help you deal with stress. Chapter 15 goes over strategies you can employ in your everyday life to manage your stress. You can also go over the relaxation techniques described in Chapter 7. Using deep breathing during stressful moments helps you calm your anxiety.

Be flexible. When you have obsessions, you usually catastrophize events and situations. You believe disasters will occur if you don’t do a certain ritual. When you think of your health, you worry about major illnesses and diseases. When you worry about your children, you think about horrible accidents or illnesses. When you worry about your house, you imagine it burning down. This type of thinking often boils over to other parts of your life. You try hard to keep your children safe, to be the perfect wife, or to never make a mistake at work. Reread Chapter 12 to learn strategies to lower your inner criticism and eliminate your need to have everything in your life turn out perfectly.

Live with uncertainty. Uncertainty is a part of life. If you have OCD, not knowing what to expect or not being able to control your environment is probably difficult. Stopping your rituals doesn’t guarantee that nothing bad is going to happen. But there isn’t any guarantee that it isn’t going to happen even when you do complete your rituals. In Chapter 17, you learn strategies for accepting that life is full of uncertainty and managing the fears that come with the unknown future.

Let go of internal measurement. If you have OCD, you might measure when to stop checking the stove when you feel “comfortable.” You might stop washing your hands when it feels “right.” These measurements are based on your internal feelings, not on facts or external measures. Those without OCD usually use more external and practical measurements. Try to come up with practical measurements for your obsessions, such as “washing my hands with soap and water for three minutes is enough.”

Don’t give your thoughts too much weight. If you have OCD, you probably disregard facts, giving your thoughts much more weight. For example, if you have a cold, you ignore the fact that your symptoms indicate you have a cold. Instead you focus on your thoughts, which tell you that this is the beginning of a serious illness. Remind yourself that thoughts are just thoughts. Work to pay attention to the facts of the situation.

Build on Successes

Each time you go through a feared situation without performing your ritual is progress. Give yourself credit for having faced your fear. Some days you might not feel like you are making any progress. Keeping a log of your fears and the exercises you complete helps. You can look through it to see if you are improving; for example, if you began with an anxiety level of 80 percent and you now have an anxiety level of 60 percent, that is progress.

Managing your OCD takes practice. Commit to using the skills in this chapter every day. Over time you will find that your fears and anxieties no longer have the same control over you they did before. Consistency is the key to learning how to manage your OCD.

There may be times when a fear resurfaces; one you thought you had conquered suddenly reappears. Don’t worry. Look back over your exercises and practice the strategies again. This time it isn’t going to take as long as it did the first time. Try to expose yourself or follow the exercises for changing your thought process as soon as possible. For example, suppose you worked on not washing your hands after touching something and a few weeks later this fear returned. You find yourself washing your hands repeatedly. Immediately refocus your attention to exposure, touching the object and not washing your hands for five minutes. Keep doing it until your anxiety level decreases.

Remember, anxiety usually lessens on its own. Anxiety rises in intensity, peaks, and then decreases. Sometimes you simply need to wait it out and give your anxiety a chance to subside.

The Least You Need to Know

• Obsessions are intrusive and upsetting thoughts. Compulsions are rituals you complete in order to alleviate the anxiety caused by your obsessions.
• Magical thinking is when you believe your rituals are linked to external events in your environment or in the world.
• Lessening your dependence on rituals will cause some discomfort in the short term, but will benefit you in the long term.
• Behavior experiments are used to test the validity and need for your rituals.