All posts by OCD

Obsessive-Compulsive Disorder and Secrecy

Great article by:

Albert Rothenberg, M.D.

Creative Explorations

https://www.psychologytoday.com/ca/blog/creative-explorations/201910/obsessive-compulsive-disorder-and-secrecy

A critically important clinical feature of obsessive-compulsive disorder (OCD) is the pervasive secrecy of patients suffering from the condition. OCD involves recurrent, disturbing thoughts and recurrent and excessive behaviors, including rituals and constant checking. Secrecy about OCD symptoms has been responsible for a long-standing, marked underestimation of the true incidence of the illness. Although clinical recognition has increased, patients’ secrecy, shame and denial continue to have an impact on assessment, treatment, and the validity of research results.

More than with many other psychiatric disorders, OCD patients do not spontaneously or voluntarily report their symptoms to health providers or even intimate family members. OCD patients fear that revealing their symptoms will lead to severe censure and disapproval because the symptoms are often ego-dystonic and seemingly antisocial or bizarre in nature: repetitive obscene or blasphemous phrases, for example, or thoughts of attacking children or loved ones or removing one’s clothes in public. Also, there is reason to believe that secrecy has its own function in both the formation and perpetuation of OCD symptoms, which serve to protect against painful anxiety.

The feelings of shame and desire for secrecy strongly influence patients’ open acknowledgment of the senselessness of symptoms. OCD patients are characteristically highly concerned with approval from other people, and their acknowledgment or denial of symptom senselessness is often determined by assumptions about the expectations of interviewers, raters or administrators of self-report measures, rather than provisions of truthful accounts. There is very likely somewhat more acknowledgment of senselessness in those indulging in checking or else cleanliness behaviors, the latter being more congruent with the values of middle-class culture and therefore more individually and socially acceptable.

Attempts at diagnostic measurement, including studies of accompanying personality disorder symptoms, have been extensively confounded by the problem of shame and secrecy. These studies have shown markedly variable results. Such wide variation in itself suggests unreliability of diagnostic instruments, but less shameful-feeling obsessive-compulsive personality disorder (OCPD) patients are also secretive about reporting certain behaviors and characteristics—in this case, irrational control, hoarding, rigidity, miserliness, and meticulous perfectionism.

Sensitive extended clinical evaluations, because of trust and familiarity developed, reveal a full range of OCD patterns. Patients will readily supply answers when asked simple questions in an unthreatening manner. The questions must rely on voluntary report and in each case, the patient should be asked to evaluate the excessiveness and inappropriateness of behaviors stipulated.

How much is “excessive”? It is up to the trained clinician together with the patient to determine the answer. This orientation is also necessary for ongoing treatment and the following of specific features of the illness. In order to determine whether the patient engages in excessive checking behavior, information is gathered about job histories, including whether one repeats tasks. If so, how often?

At home, how many times is the lock on the door tested when the patient goes out, how often are the stove burners checked, how long does it take to dress in the morning? In order to assess cleanliness, the patient is asked about patterns of housekeeping, showering and handwashing. Are particular places avoided because of possible contamination or dirt? For symmetry and order, questions are directed toward preferred placement of objects in the home, pictures on the wall, and preferences about physical work environments.

For assessment of obsessional thinking, information is effectively evoked by identifying everyday difficulties in living and performing. Commonly reported problems in sleeping are followed by questions about the possibility of bothersome or repetitive thoughts that keep the patient awake. Similarly, if a patient reports distractions and inability to concentrate at work or at school, questions are asked about mental preoccupations.

Obsessive-compulsive disorder has long been hidden and difficult for both sufferers and therapists. Currently, various treatments are available with varying degrees of promise. A number of SSRI medications have shown beneficial effects, including clomipramine, fluoxetine, paroxetine, sertraline, and fluvoxamine—and psychotherapy is an absolute must.

Mental IMAGES

OCD is defined as: Obsessions are unwanted and repetitive thoughts, urges, or images that don’t go away. They cause a lot of anxiety. These obsessive thoughts can be uncomfortable. Obsessions aren’t thoughts that a person would normally focus on, and they are not about a person’s character. They are symptoms of an illness.

I wanted to shed light on mental images in OCD, a lot of times people who do know about OCD know about the intrusive thoughts or the compulsions. But what about the mental images? Many people who suffer with OCD are plagued by mental images that are often disturbing & distressing in nature. This makes the fears amplified to the point of the individual now picturing in detail their worst nightmares. Aaron Harvey describes it in an interview with Cosmopolitan.

“One of the things I have to deal with the most is harm OCD, and it’s really challenging. When I step into the shower and see the razor blade, it will automatically trigger [an image of] me, like, mutilating my genitalia. If I react to those images, they just get worse. It’s kind of like living in a nightmare. …I’ve struggled with sexual identity as a result of repeated, intrusive sexual thoughts about men, despite being straight. During sex, I may have dozens of intrusive thoughts spanning incest, violence, and other unwanted imagery that steals the beauty of the moment. I have graphic flashes of friends and strangers engaging in bizarre sexual acts” – Aaron Harvey (creator of instrusivethoughts.org)

The images are extremely debilitating, and getting to a point where you are okay with just allowing them to pop in and out is extremely painful and difficult. The images cause a lot of distress, so suffers gut reaction is to try their hardest to get rid of the thoughts. But as we know trying to push away and resist the thoughts fuels OCD and makes it worse.

ERP is a great tool against the images, exposing yourself to the images and not allowing yourself to engage in compulsions will allow the reaction subside. To really challenge yourself purposely try and think of the images and confront the discomfort.

Exposure Response Prevention, commonly referred to as ERP, is a therapy that encourages you to face your fears and let obsessive thoughts occur without ‘putting them right’ or ‘neutralising’ them with compulsions.

Exposure therapy starts with confronting items and situations that cause anxiety, but anxiety that you feel able to tolerate. After the first few times, you will find your anxiety does not climb as high and does not last as long. You will then move on to more difficult exposure exercises.

Being asked to face your fears is perhaps one of the bravest aspects of treatment, and is where the approach of the therapist is most valuable, helping a person understand the cognitive reasons behind an exercise and being there to help encourage and motivate them to face the challenges it involves.  If the therapist actually participates in the exercises too, this helps build up trust and confidence in what they are asking the person with OCD to do.

Uncertainty

OCD at its core is the inability to accept uncertainty. Life is uncertain and no one can predict the future, and for someone with OCD they will try relentlessly to try and to figure out how to reassure themselves and predict the future. OCD knows you the best out of anyone and will use that as a weapon against you. The content of the OCD does not matter it can shift to different forms and will try any angle to get your attention. If it isn’t getting a reaction it will change its approach until you fold. Remember it is not about getting rid of the thoughts, but living with them and changing your reaction. A common hurdle with dealing with OCD is the inability to accept that having these thoughts and ideas are natural and everyone experiences them. A sufferer will become so terrified that they start to resist and carryout compulsions, which just makes things worse. I met Jonathan Greyson at the conference, someone I have been admiring for years, his books, videos, and work have truly changed my life and my outlook on OCD. At the conference he told me an important message when OCD keeps attacking responding with “maybe it will happen or maybe it wont” the idea here is that we don’t know what will happen and being okay with living with MAYBE will help the brain be okay with any thoughts. I would highly recommend practicing this technique, any thought that pops up that triggers fear respond with this, I know it is easier said then done especially because OCD can be present all moments of every waking hour, but it gets easier the more you practice. Doing this while practicing ERP to purposely challenge your fears will help significantly. It is extremely important to find a therapist who is trained in ERP the IOCDF website has an approved list of therapists who know how to treat OCD:

OCD Conference 2019

I just came back from the annual OCD conference in Austin, TX and it was incredible! I encourage anyone who is suffering with OCD to attend the conference, not only are you around pioneers in the field like Doctor Johnathan Grayson and Jon Hershfield, but to meet like minded individuals is just so incredible. The conference was full of resources, talks, peer supports and so much more!

Here are a few key take aways:

  1. The doctors from Bergen Norway came to present around the 4-Day Bergen Treatment
  2. Brainsway TMS received FDA approval and will be getting approval in Canada most likely by the end of this year
  3. ERP (Exposure Therapy) is the gold standard
  4. ACT (Acceptance and Commitment Therapy) helps with pushing yourself past the thoughts and the pain by practicing mindfulness and radical acceptance
  5. Suffers with OCD are the kindest, bravest and most compassionate people I have ever met I will hold on to these incredible interactions for ever.

Next years conference is hosted in Seattle!! See below for information:

https://www.ocd2019.org/events/26th-annual-ocd-conference/custom-38-ae4b5eb661f7421da58d467be6eba399.aspx

Living With Someone Who Has OCD. Guidelines for Family Members

Great Article and Tips from the IOCDF website:

From the Experts

These articles are about special topics related to OCD and related disorders. For more general information, please visit our “About OCD” section.

(From Learning to Live with OCD)

By Barbara Van Noppen, PhD and Michele Pato, MD

This article was initially published in the Spring 2009 edition of the OCD Newsletter

In an effort to strengthen relationships between individuals with OCD and their family members, and to promote understanding and cooperation within households, we have developed the following list of useful guidelines. These guidelines are meant as tools for family members to be tailored for individual situations, sometimes more powerfully employed with the help of a therapist with expertise in working with OCD.

1. Recognize Signals

The first guideline stresses that family members learn to recognize the “warning signals” of OCD. Sometimes people with OCD are thinking things you don’t know about as part of the OCD, so watch for behavior changes. It is important to not dismiss significant behavioral changes as “just their personality.” Remember that these changes can be gradual, but overall different from how the person has generally behaved in the past.

Signals to watch for include but are not limited to:

  • Large blocks of unexplained time that the person is spending alone (in the bathroom, getting dressed, doing homework, etc.)
  • Doing things again and again (repetitive behaviors)
  • Constant questioning of self-judgment; excessive need for reassurance
  • Simple tasks taking longer than usual
  • Perpetual tardiness
  • Increased concern for minor things and details
  • Severe and extreme emotional reactions to small things
  • Inability to sleep properly
  • Staying up late to get things done
  • Significant change in eating habits
  • Daily life becomes a struggle
  • Avoidance
  • Increased irritability and indecisiveness

People with OCD usually report that their symptoms get worse the more they are criticized or blamed because these emotions generate more anxiety. So it is essential that you learn to view these features as signals of OCD and not as personality traits. This way you can join the person with OCD to combat the symptoms, rather than become alienated from them.

2. Modify Expectations

People with OCD consistently report that change of any kind, even positive change can be experienced as stressful. It is often during these times that OC symptoms tend to flare up; however, you can help to moderate stress by modifying your expectations during these times of transition. Family conflict only fuels the fire and promotes symptom escalation, (“Just snap out of it!’). Instead a statement such as “No wonder your symptoms are worse— look at the changes you are going through,” is validating, supportive and encouraging. Remind yourself the impact of change will also change; that is the person with OCD has survived many ups and downs, and set backs are not permanent. You must adjust your expectations accordingly which does not mean to not expect something!

3.Remember That People Get Better at Different Rates

There is a wide variation in the severity of OC symptoms between individuals. Remember to measure progress according to the individual’s own level of functioning, not to that of others. You should encourage the person to push him/herself and to function at the highest level possible; yet if the pressure to function “perfectly” is greater than a person’s actual ability it creates more stress which leads to more symptoms. Just as there is a wide variation between individuals regarding the severity of their OC symptoms, there is also wide variation in how rapidly individuals respond to treatment. Be patient. Slow, gradual improvement may be better in the end if relapses are to be prevented.

4. Avoid Day-To-Day Comparisons

You might hear your loved ones say they feel like they are “back at the start” during symptomatic times. Or you might be making the mistake of comparing your family member’s progress (or lack thereof) with how he/she functioned before developing OCD. It is important to look at overall changes since treatment began. Day-to-day comparisons are misleading because they don’t represent the bigger picture. When you see “slips” a gentle reminder of “tomorrow is another day to try” can combat self destructive labeling of “failure,” “imperfect,” or “out of control” which could result in a worsening of symptoms! You can make a difference with reminders of how much progress has been made since the worst episode and since beginning treatment. Encourage the use of questionnaires to have an objective measure of progress that both you and your loved one can refer back to (for example, the Yale Brown Obsessive Compulsive Scale) Even a 1-10 rating scale can be helpful. Ask “How would you rate yourself when OCD was at it’s worst? When was that? How is it today? Let’s think about this again in a week.”

5. Recognize “Small” Improvements

People with OCD often complain that family members don’t understand what it takes to accomplish something, such as cutting down a shower by five minutes, or resisting asking for reassurance one more time. While these gains may seem insignificant to family members, it is a very big step for your loved one. Acknowledgment of these seemingly small accomplishments is a powerful tool that encourages them to keep trying. This lets them know that their hard work to get better is being recognized and can be a powerful motivator.

6. Create a Supportive Environment

The more you can avoid personal criticism the better – remember that it is the OCD that gets on everyone’s nerves. Try to learn as much about OCD as you can. Your family member still needs your encouragement and your acceptance as a person, but remember that acceptance and support does not mean ignoring the compulsive behavior. Do your best to not participate in the compulsions. In an even tone of voice explain that the compulsions are symptoms of OCD and that you will not assist in carrying them out because you want them to resist as well. Gang up on the OCD, not on each other!

7. Set Limits, But Be Sensitive to Mood (refer to #14)

With the goal of working together to decrease compulsions, family members may find that they have to be firm about:

  1. Prior agreements regarding assisting with compulsions;
  2. How much time is spent discussing OCD;
  3. How much reassurance is given; or
  4. How much the compulsions infringe upon others’ lives.

It is commonly reported by individuals with OCD that mood dictates the degree to which they can divert obsessions and resist compulsions. Likewise, family members have commented that they can tell when someone with OCD is “having a bad day.” Those are the times when family may need to “back off,” unless there is potential for a life-threatening or violent situation. On “good days” individuals should be encouraged to resist compulsions as much as possible. Limit setting works best when these expectations are discussed ahead of time and not in the middle of a conflict. It is critical to minimize family accommodation to OCD.

8. Support Taking Medication as Prescribed

Be sure to not undermine the medication instructions that have been prescribed. All medications have side effects that range in severity. Ask your family member if you could periodically attend their appointments with the prescribing physician. In this way you can ask questions learn about side effects and report any behavioral changes that you notice

9. Keep Communication Clear and Simple

Avoid lengthy explanations. This is often easier said than done because most people with OCD constantly ask those around them for reassurance. “Are you sure I locked the door?” or “Did I really clean well enough?” You have probably found that the more you try to prove that the individual need not worry the more he disproves you. Even the most sophisticated explanations won’t work. There is always that lingering “What if?” Tolerating this uncertainty is an exposure for the individual with OCD and it may be tough. Recognize that the person with OCD is triggered by doubt, label the problem as one of trying to gain total certainty about something that cannot be provided, this is the essence of OCD and the goal is to accept uncertainty in life. Avoid lengthy rationales and debates.

10. Separate Time Is Important

Family members often have the natural tendency to feel like they should protect the individual with OCD by being with him all the time. This can be destructive because family members need their private time, as do people with OCD. Give them the message that they can be left alone and can care for themselves. Also, OCD cannot run everybody’s life; you have other responsibilities besides “babysitting.” You need and deserve time to pursue your interests too! This not only keeps you from resenting the OCD it is also a good role model to the person with the OCD that there is more to life than anxiety.

11. It Has Become All About the OCD!

Whether it is about asking and providing reassurance to the family member with OCD or talking about the desperation and anxiety that the illness causes, families struggle with the challenge of engaging in conversations that are “symptom free,” an experience that feels liberating when achieved. We have found that it is often difficult for family members to stop engaging in conversations around the anxiety because it has become a habit and such a central part of their life. It is okay not to ask ”How is your OCD today?” Some limits on talking about OCD and the various worries is an important part of establishing a more normative routine. It also makes a statement that OCD is not allowed to run the household.

12. Keep Your Family Routine “Normal”

Often families ask how to undo all of the effects of months or years of going along with OC symptoms. For example, to “keep the peace” a husband allowed his wife’s contamination fear to prohibit their children from having any friends into the household. An initial attempt to avoid conflict by giving in just grows; however, obsessions and compulsions must be contained. It is important that children have friends in their home, or that family members use any sink, sit on any chair, etc. Through negotiation and limit setting, family life and routines can be preserved. Remember it is in the individual’s best interest to tolerate the exposure to their fears and to be reminded of others’ needs. As they begin to regain function, their wish to be able to do more increases.

13. Be Aware of Family Accommodation Behaviors (refer to #14)

First there must be an agreement between all parties that it is in everyone’s best interest for family members to not participate in rituals (Family Accommodation Behaviors). However, in this effort to help your loved one reduce compulsive behavior, you may be easily perceived as being mean or rejecting, even though you are trying to be helpful. It may seem obvious that family members and individuals with OCD are working toward the common goal of symptom reduction but the ways in which people do this varies. Attending a family educational support group for OCD, or seeing a family therapist with expertise in OCD, often facilitates family communication.

14. Consider Using a Family Contract

The primary objective of a family contract is to get family members and individuals with OCD to work together to develop realistic plans for managing the OC symptoms in behavioral terms. Creating goals as a team reduces conflict, preserves the household, and provides a platform for families to begin to “take back” the household in situations where most routines and activities have been dictated by an individual’s OCD. By improving communication, and developing a greater understanding of each other’s perspective, it is easier for the individual to have family members help them to reduce OC symptoms instead of enable. It is essential that all goals are clearly defined, understood, and agreed upon by any family members involved with carrying out the tasks in the contract. Families who decide to enforce rules, without discussing it with the person with OCD first, find that their plans tend to backfire. Some families are able to develop a contract by themselves, while most need some professional guidance and instruction. Be sure to reach out for professional assistance if you think that you could benefit from it.

Barbara Livingston Van Noppen, PhD is an Associate Professor in the Department of Psychiatry and Human Behavior and Assistant Chair of Education Keck School of Medicine University of Southern California.Dr. Van Noppen provides CBT supervision and didactic education to psychiatric residents in the USC Keck School of Medicine program.

Michele Tortora Pato, MD is the Della Martin Chair in Psychiatry and Associate Dean for Academic Scholarship at the Keck School of Medicine-USC.