Self Help Guide to Obsessive Compulsive Disorder
Obsessive Compulsive Disorder (OCD) is an anxiety disorder dominated by obsessions (intrusive thoughts, images) and compulsions (rituals, urges and behavioural responses to the thoughts). On the physical level, anxiety is the body's alarm signal. It is the body’s normal and adaptive signal that we are in danger. Dealing with our anxiety never involves eliminating it but rather managing it. Anxiety becomes a problem when our body tells us there is danger when there is no real danger.
A lot of people with OCD feel very responsible for preventing a terrible thing from happening (e.g. I must keep bacteria away from my family otherwise they might become ill or die and it will be my fault"). Others do not have these catastrophic thoughts, but might feel very uncomfortable and become increasingly anxious and distressed if they don't do what their head is telling them to do.
Compulsions can be 'overt' or obvious behaviours such as cleaning, touching or checking, or 'covert' hidden mental rituals such as counting, repeating things, questioning or mental checking. A few people only experience obsessions, and a small minority only compulsions.
There are some other variants of OCD, such as trichotillomania (hair pulling), compulsive skin picking, and Body Dysmorphic Disorder (BDD) in which the person believes a particular part of their body is defective and they constantly check, scan, and plan, or make attempts to hide or change the 'defect'.
In order to break the vicious cycle of OCD, we need to change the way we think (and think about thoughts) and change what we do. A proven successful therapy for OCD is Cognitive Behavioural Therapy (CBT). CBT focuses on challenging the unhelpful thoughts and beliefs, and learning to resist the urge to act through Exposure & Response Prevention (ERP) Therapy.
THINKING DIFFERENTLY: The OCD Bully
Thinking Differently involves challenging the thoughts and thinking about thoughts in a completely different way. Let's think about an imaginary playground bully in a school. This particular bully isn't violent, but he taunts, teases, laughs and criticises. Cruel words. Imagine this bully picks on 3 victims this playtime. He approaches each victim with the same taunts: "Hey you! You're so stupid - give me your lunch money NOW or else I'll tell everyone how stupid you are!" How does each victim react?
Victim number 1 believes the bully, becomes upset and hands over the money.
Victim number 2 challenges back - "I'm not stupid, I got 8/10 in my spelling test this morning, you only got 4. Get lost!"
Victim number 3 hardly reacts at all. He looks at the bully to acknowledge him, then turns around to go and play football with his friends.
How does the bully react to each? He's probably going to come back to victim 1 most days. He might have another go at victim 2, but he'll soon give up. The bully's probably not going to bother victim 3 much.
Our own OCD bully is just like that playground bully, and instead of reacting like victim number 1, believing the bully and doing as he says, we can choose to react like victim number 2. We can learn to challenge our OCD bully. Or better still we can, like victim 3, simply acknowledge the bully, then let the thought go and shift our focus of attention by doing something else.
Thinking Differently - Challenging Thoughts
If we can change the way we think about a situation, then we will not feel so anxious. We can learn to challenge those anxiety-provoking thoughts. Thoughts are not statements of fact. Don't believe everything you think!
What we believe deep down about ourselves, others and the world, influences and distorts the way we make sense of everyday life. Just because we think something bad might happen, doesn't mean that is how it really is! We are looking at life and situations through those very distorted lenses.
One of the features of OCD is an inflated sense of responsibility. For example: "Something awful will happen if I don't do this compulsion, and it will my fault if it happens", "If I think about this happening, it will happen if I don't prevent it by doing this compulsion". Learn to challenge the unhelpful and distorted thinking. Practice observing the thoughts behind your compulsions and begin to question are thay really true or not.
Thinking Differently - Letting the thoughts go
Another way of looking at The Mind Bully is this. We tend to react to thoughts by fighting with them, because they are so upsetting, we just want to get rid of them. The best thing to do seems like fighting them away or trying to stop them, but maybe that's not so helpful. If you try NOT to think about a green elephant right now, for 30 seconds - DO NOT think about a green elephant and DO NOT imagine seeing a green elephant. Try it for 30 seconds.
What happened? You thought of a green elephant? That's how the mind works. When we're on a diet, all we can think about is food, right? The more we try NOT to think about something, the more it keeps popping up into our heads. Like trying to push a beach ball down under the water. We have to keep the pressure up and keep pushing down, but it just keeps popping back up into our face. If we let it go, the ball would just drift about. It might nudge us from time to time, but that's ok, we can just let it be. We could pull the rope in a tug-of-war with the bully, but we could also just let the rope go. So we can let these troublesome bullying thoughts go with three steps:
Acknowledge the OCD bullying thought
Let the thought go
Switch focus and do something else
Thinking Differently - Mindfulness
We easily get caught up in our thoughts and discomfort. It is very helpful to learn to change our focus of attention, so that the distressing thoughts and feelings, whilst still there, fade a little into the background. It is easiest and most effective to start with our breathing as that will also calm down the body's adrenaline response to anxiety.
Mindfulness is another excellent way to change our focus of attention. One mindfulness activity that you can practice at any time you have a spare moment like waiting in a que is ‘mindful activity’ which you can do in three steps:
Notice what your attention is on.
Observe what you are doing and name that activity in your mind with ‘I am…’ statements: "I am walking", "I am sitting", "I am breathing". Then notice whatever sensations those activities bring up in your body
Decide: What now? How shall I continue this activity or move on to another?
Another mindful activity is to choose something to do with great attention for one, two or five minutes. For example: Drink a cup of tea. Walk. Wash the dishes.
Whatever you are doing, be in that moment, right now. See, hear, smell, touch, feel, breathe.
Simply notice whenever other thoughts and sensations come to mind, then re-focus on your chosen mindful activity.
Be patient and compassionate with yourself.
Describe, rather than judge good or bad, pleasant or unpleasant.
It is as it is.
DOING DIFFERENTLY: Exposure and Response Prevention Therapy
Doing the compulsion in response to our thoughts serves to keep the OCD anxiety going because we never learn that NOT doing it wouldn't result in the feared consequence. Not doing the rituals or checking is therefore going to provoke anxiety initially, but we can use our coping strategies to tolerate that discomfort, and we will learn that just because we had a thought, we don't have to do the compulsion and the feared event does not happen.
Exposure and Response Prevention (ERP) is the type of behavioural therapy for OCD. It simply means being exposed to the thought or situation that makes you feel anxious, and NOT responding to it by doing the compulsion.
1. Get to know your OCD better – Obsession Monitoring Form
To face your fears, it is helpful to know what you are thinking (your obsessions) and identify the triggers that bring on your obsessions and compulsions.
You can do this by keeping track of the triggers on a daily basis for 1 week by drawing up an Obsession Monitoring Form with 5 colums under the following headings: Date; Triggers for Obsession; Obsessions; Fear and Compulsions/Coping Strategies.
Because obsessions can happen frequently, writing down 3 triggers per day (e.g. 1 in the morning, 1 in the afternoon, and 1 in the evening) will be enough to give you a good overview of your obsessions and compulsions.
In the column labelled “Fear”, rate how intense the fear was in the specific situation. Use a 0-10 rating scale, where 0 = no fear and 10 = extreme fear.
Finally, record all the compulsions/coping strategies you used in response to the obsession. Be sure to include both behavioural and/or mental strategies you used to manage the obsession and fear.
Try to make an entry as soon as possible after the episode as this will help you to be more precise. You may want to keep a small notebook with you that you can easily carry around.
2. Build a fear ladder
After about 1 week of tracking your obsessions and compulsions, you will be ready to make a list of all the different situations that you fear.
Build a fear ladder by rank, ordering your triggers from least scary to most scary. For example, if you have contamination fears, being at a friend’s apartment may be a situation that is low on the fear ladder because it only evokes a fear of 1/10. But using the bathroom in a shopping mall may be a situation that is very high on the ladder because it evokes a 9/10 fear.
TIP: Build a separate ladder for each of your obsessive fears. For example, you may need a separate hierarchy for all situations related to your fear of contamination. You may also need a separate ladder for all situations related to your fear of causing something terrible to happen.
3. Climbing the fear ladder – ERP
Once you have built a fear ladder, you are ready to face your fears by putting yourself in situations that bring on your obsessions (exposure), while resisting doing anything to control the obsessions and the anxiety associated with them (response prevention).
TIP: Feeling anxious when you try these exercises is a sign that you are on the right track.
Bottom up. Start with the easiest item on the fear ladder first (i.e. fear=2/10) and work your way up.
Don’t avoid. During exposure, try not to engage in subtle avoidance (e.g. thinking about other things, talking to someone, touching the doorknob only with one finger instead of the whole hand, etc.). Avoidance actually makes it harder to get over your fears in the long term.
Don’t rush. It is important to try to stay in the situation until your fear drops by at least half (e.g. from 6/10 to 3/10). Also, focus on overcoming 1 fear at a time. It is a good idea to do the exposure repeatedly until the first item on the hierarchy no longer causes much of a problem for you.
TIP: Regardless of its intensity, a fear will peak and then level off. If you do nothing about it, the fear will eventually go away on its own.
4. How to do Response prevention
As you practise these techniques, you are still going to feel the anxiety and physical discomfort that goes with it when you don't immediately respond to the thought by doing the compulsion. However, practise the ‘STOPP’ strategy to help you cope with this discomfort:
Stop. Take some deep breaths
Observe: feel the fear and discover the obsessive thoughts that go with it – my tooth will decay if I don’t clean more; I will get infection if I touch the laces or touch the door handle;
Name the thoughts as obsessive, as over reactions to a problem, as an unhelpful part of yourself, as not the real you. Replace the thought with more factual thoughts. “1 min of cleaning my teeth is enough.” “I will not get contaminated if I touch the door handle”.
Divert your energies onto hopes, personal goals and enjoying your hobbies and interests.
Each time you do NOT do the compulsion, your mind finds out that the thing you feared happening, didn't happen, which will help you to challenge that same thought when it happens again. It takes a while for that information to sink in, but eventually your mind realises you just don't need to believe or take notice of these thoughts any more - so they lose their power over you. The thoughts may not stop happening, but you don't have to believe everything you think!