OCD: The Doubting Disease Some may have heard of OCD referred to as “the doubting disease”. This label is actually not an inaccurate one.OCD, at its very core, is a disorder that emerges from a fear of doubt and uncertainty. All human beings are hard-wired to try to reduce doubt and uncertainty when they feel unsafe.But throughout life, we are faced with situations in which there is no certainty.And indeed, if we think hard enough about it, it may be difficult to identify things that we can be 100% certain of, of which there is 0% doubt.But most of us are comfortable to go through life accepting a certain degree of uncertainty as we live our lives. But what if a situation arises in which you believe you can't accept any uncertainty? That, for whatever reason, you believe that you must remove all doubt? Obsessive Compulsive Disorder is a fear of uncertainty coupled with an unwillingness to tolerate it.
Obsessive Thoughts Obsessions are nothing more than thoughts--repetitive, intrusive and sometimes maddening thoughts.Obsessions can relate to literally any topic that can possibly occur to a human being. In popular media, individuals with OCD are often portrayed as having obsessions about contamination and germs. And while some individuals with OCD do have obsessions about germs, this is but one of the infinite number of topics that can become an obsession.
Obsessive thoughts can be about whether we may inadvertently cause harm to ourselves or our loved ones, about whether we might carelessly make an error in our work that would damage our future prospects, about whether our thoughts about sex suggest that we may become a sexual deviant, about why a particular part of our body feels strange, about whether or not we are hearing, reading or seeing things correctly, about whether we will go to heaven, about whether we might be misunderstanding things, about why a particular physical movement or daily activity feels "off" or "wrong", or about whether we might impulsively do something harmful or embarrassing. And while many individuals with OCD have obsessions about topics that are either scary or taboo, obsessions can also be about the most mundane of topics that appear to have no relevance or import to our lives. The rule is, if you can doubt it, it can be an obsession. And what can human beings doubt? What topics or assumptions can we feel uncertain about? The answer is ANYTHING.Humans can come to doubt or feel uncertain about literally anything. Even the most irrelevant thought can become maddening if it's put on a never-ending loop that repeats itself over and over in our mind.
Whether scary or mundane, obsessions invariably result in us asking ourselves the same questions...why am I having this thought? Why can't I stop myself from thinking about this? What does this thought mean? This process of questioning and attempting to figure out the cause of our obsessional thoughts often becomes its own monster, it's own obsession. Family members of individuals with OCD may find themselves saying things like, "Just don't worry about it!" "Just stop thinking about it!" and "Don't let it bother you!" They may feel frustrated that their loved one continues to focus on things that cause them distress. They might be confused about why the individual doesn't just "move on" or let go of the thoughts. And while to outsiders it seems as though it should be easy to just stop thinking about it, to the individual with obsessions, it is just not that simple. They are living with a broken record, an unending and repetitive soundtrack that plays in their mind and that feels impossible to stop.
Compulsive Behaviors Just as obsessive thoughts can be about anything that comes into the human mind, compulsive behaviors can be any possible action or activity that can be performed by a human being. Most people have heard about compulsions that involve excessive cleaning or hand washing. In fact, this stereotypical representation of an OCD compulsion has become so widely known that it is now common for people who are very clean or organized to say, "I'm so OCD." But as any individual who suffers from OCD will tell you, this colloquial usage minimizes the experience of those whose lives are consumed by the disorder. Far from typical fastidiousness with hand-washing, the individual with OCD may feel compelled to wash their hands until their skin becomes raw. Compulsions can be extreme and all consuming. Many individuals with OCD spend much of their day engaging in a repetitive cycle of obsession and compulsion.
Compulsions can include checking, washing, repeating, collecting, ordering, confessing, asking, researching, counting, praying, and avoiding (just to name a few!). These behaviors can look quite different from person to person, which is one of the factors that makes it difficult for untrained clinicians to spot the disorder. For example, checking compulsions can focus on the more common checking of the locks and the stove, but they can also focus on checking almost anything else.Individuals may repeatedly checkthat they didn't lose something, check for mistakes, they may turn their car around to check that they didn't hit someone, ask numerous questions to check to see if they are perceiving things correctly, check to see if they may have a disease, check on their loved ones, and on and on.
Most individuals with OCD have compulsions that cluster into one or two categories, while others have compulsions that run the gamut. It is not a single behavior or a series of behaviors that defines an OCD compulsion. The best way to identify a compulsion is to understand the purpose that they serve. Individuals with OCD engage in compulsions in order to reduce the uncertainty and doubt that is triggered by their obsession. An individual who fears illness may engage in compulsive hand washing to try to feel "certain" that they will not catch a disease.A person who fears that they might engage in sinful behavior might compulsively confess each small infraction to feel sure they will go to heaven. Someone who fears that they might have unwittingly run someone over with their car may turn their car around and retrace their route, compulsively checking the road for victims, so that they can be 100% sure that they haven’t hurt someone.Someone who fears that they may be “going crazy” may compulsively research mental health on the internet to be sure that they are sane. Someone who fears that they might choke may avoid foods that are sticky and may cut their food into tiny pieces in an effort to attain certainty that they will not choke. An individual who fears that they will make a mistake may read the same part of a book over and over again to feel "sure" that they are understanding it or remembering it properly. Someone who repeatedly asks a loved one how they feel might be trying to be "absolutely positive" that their loved one won't die.
Often times, individuals engage in compulsions to make themselves feel more comfortable or to reduce their distress. At other times, people with OCD won't even report distress or anxiety, they will simply engage in compulsions because something doesn't "feel right." Compulsions may be done until it feels "right" or "clean" or "certain" or "finished" or until the individual's anxiety or distress decreases. But at the very core of all compulsions is the desire to eliminate uncertainty. And for a time, compulsions will make people believe that they can be certain of things, that the doubt has been removed. But invariably, uncertainty creeps back in and the individual finds themselves having to go to greater and greater lengths to feel sure of things. And in this never-ending cycle of compulsions to reduce uncertainty, individuals chase the feeling that things are “right” or “finished”.But this sense of confidence and completeness becomes ever and ever more elusive and the individual experiences greater distress as they go to greater lengths to feel better. And sometimes nothing works.At those times, OCD sufferers may believe they are having a “break down” or they may completely exhaust themselves.
Compulsions May Appear Illogical While some of the compulsions appear to make logical sense to the observer, others seem to have no logical connection to the obsessive thought and may even look bizarre. But despite the fact that the connection may not be obvious to others,there is generally some explanation for how the compulsion came to be what it is.For example, certain types of repetitive behaviors may start in response to some internal sense that the first try at an action "didn't feel right" and the individual may wonder if they actually completed the activity. This is a common enough experience. Which of us hasn’t locked our car or turned off the stove, only to second guess ourselves and feel compelled to do it again? The action is repeated, and then we confirm that it is done—we feel "certain" and we move on. But the individual with OCD has a different experience.While a single repetition may work well one day, it might not work on another day.They may check a lock once but then continue to have a nagging feeling that it’s not done.So they might check again, or they might do something a little differently—like pull on the door handles just to be certain they are locked.But what if they walk away and it still doesn’t feel quite right? As time goes on, the individual tries different combinations of behaviors that sometimes work and sometimes don’t.They become stuck in a maddening cycle in which the feeling of confidence that “its done” is always just slightly out of reach.They may desperately try to get back the sense of certainty that they could originally achieve with just checking once or twice.
Over the course of months and years, the routine of checking the door locks may bear little resemblance to where it started.In this manner, compulsions may come to look somewhat bizarre to the observer.OCD sufferers may feel compelled to say a certain word or phrase or engage in a particular movement a certain number of times or they may demand that others say or do certain things. They may pray in a very specific and repetitive manner, they may arrange and rearrange their items, they may repeat what others say, repeat various activities over and over, repeating actions a specific number of times and count out loud or to themselves as they are doing things. They may spend considerable portions of their day compulsively trying to "figure out" why they are having certain thoughts, researching the internet or quizzing their friends or family to try to find answers about why they are having certain thoughts or whether or not their thoughts and feelings are normal.
“Pure O” or “Primary O” While some compulsions are obvious to the observer, other compulsions may not be visible at all.There is a concept in OCD research known as “Pure O” or “Primary O”, which describes a form of OCD in which obsessions appear to exist without compulsions.The “Pure O” concept has more recently been clarified and it is now more commonly used to describe individuals with OCD in which the behavioral compulsions are simply more subtle or are not visible to the observer.But this does not mean that the compulsions to not exist.Some individuals who do not engage in more overt compulsions may compulsively engage in a “mental review” oftheir personal history.They may re-play events that just happened over and over again in their mind.They may mentally “scan” their body, searching for unusual sensations that could indicate problems.Their primary compulsion may be “researching” and they may spend hours scouring the internet in an effort to reassure themselves that their obsessive fear is unwarranted.They may engage in lengthy discussions or spend hours of time deep in thought, compulsively trying to “figure out” why they feel or think in the way they do.
Exposure and Response Prevention (ERP) The clinicians at Belmont Psych are all highly skilled in the application of the treatment of choice for OCD, which is Exposure and Response Prevention. ERP for OCD involves allowing yourself to experience uncertainty and discomfort without engaging in any compulsion or avoidance to reduce its impact.An “Exposure” is simply allowing yourself to face your fears.To engage in a behavior, or have a particular thought, or feel a particular feeling that has previously been avoided.“Response Prevention” is the term used to describe the process of resisting the urge to engage in a compulsion or to run from the uncomfortable thoughts and feelings that invariably come when we face our fears.
It is not uncommon for therapists to believe they understand how to provide treatment for OCD, but in reality, they do not have the supervised experience or the training to manage the complexities of the disorder. Many untrained clinicians believe that the focus of treatment should be on trying to “calm down” or to “stop thinking about it.”This type of treatment is likely only to frustrate the individual in the throws of their obsessions and compulsions.The truth of the matter is that the more we try to “stop thinking” about something, the more likely it is that we will think about it.The more we try to “calm down” as we approach the discomfort of facing our fears, the more distressed we often become.It is essential that the therapist you choose be proficient in the use of ERP.
The focus in ERP is on learning to tolerate the “not right” feeling, learning to cope with the distress, and most importantly, learning to accept uncertainty.We are often asked by our patients, "But isn’t it normal to want to feel safe and be certain of things?" And absolutely, it is very normal and natural for human beings to desire safety, certainty and security. The question is....how certain must we be? The answer to that question typically differs depending on the particular obsession. Individuals dealing with OCD generally have a number of obsessions that fuel their compulsive behaviors.Some of their compulsions will be easier to resist because the feared consequences aren’tas scary. Some compulsions will feel impossible to resist because the obsession is so frightening.In ERP treatment, you will work with your therapist to figure out a plan that will help you address the less scary obsessions first and then progress to the more difficult ones.
OCD is a Bully- Don't give in! OCD is a bully who will tell you that you can't tolerate uncertainty. OCD will tell you that you MUST do something to get rid of your doubts and discomfort. For the individual with OCD, it feels as though the obsessions will pester you and pester you until you cave in and engage in the compulsions. But OCD is a bully, and we know what happens when we give in to a bully. If you give in and give a bully your lunch money, the bully will demand more. OCD can take everything from you if you allow it. And while it is scary to stand up to a bully, and while it may feel easier to just “give in” to get the bully off of your back, it is only by standing up to the bully and allowing yourself to be scared that the bully will eventually leave you in peace. If you are reading this and you know that it describes you, perhaps you'll be willing to take a step further and call us. Or, if you would like to learn more about OCD and start taking steps on your own to get better, consider one of the excellent resources listed below that are regularly recommended by our team.
Therapy Is More Than A Conversation Some critics of psychotherapy have likened the role of the therapist to a friend who is paid to sit and chit chat with clients about their lives or just listen while people complain. And while some therapists do perhaps provide little more than emotional support, the role of the Cognitive Behavior Therapist is different. CBT involves providing a great deal of education, helping clients to remember and use that education, teaching concrete skills, and tracking progress to confirm that patients are benefitting. It is our hope that that by reviewing the information provided on this website, that anyone who is interested in our services, or in any therapist's services for that matter, is able to appreciate the difference it makes to work with well-trained Cognitive Behavior Therapists.
Local therapists who are interested in learning to treat this complex disorder may call Dr. Katy Manetta, the Clinical Training Director, at 562-799-6700 to discuss the training opportunities available at Belmont Psych.
Dr. Jonathan Grayson, author of "Freedom From Obsessive Compulsive Disorder" at an in-service training and consultation with some of our Belmont Psych Psychologists.