Could it Be OCD?: A Primer on OCD and its Treatment

According to the International OCD foundation, “about 1 in 40 adults have OCD or will develop it at some point in their lives”.  While this is one of the most common psychological disorders, it is also one of the most commonly misdiagnosed – with some studies indicating that as many as half of those experiencing OCD are given incorrect diagnoses for over a decade prior to proper assessment (see: https://pubmed.ncbi.nlm.nih.gov/26132683/,https://www.sciencedirect.com/science/article/abs/pii/S2211364921000737,https://www.sciencedirect.com/science/article/pii/S2666915321001578).  OCD is a psychological chameleon, changing shape dramatically from one person to the next, often mimicking other disorders.  If you suspect that you may have OCD it is important that you seek out a professional who is trained in OCD to get an accurate assessment.   

OCD is easy to misdiagnose. Even otherwise amazing practitioners often have very limited education on OCD and can get confused when OCD is masquerading as another disorder, or when there is also significant trauma taking center stage.  Someone who struggles with unwanted intrusive thoughts about suicide (and who have no intention of acting on these impulses) for example, might be treated as if they are actually suicidal; Or a client who has unwanted (and nonpleasurable) sexual thoughts about taboo sexual partners might be considered a risk for dangerous sexual behavior.  Another OCD-sufferer who believes that if they forget to wear blue on Mondays they will trigger an earthquake, might understandably be diagnosed with delusional disorder.  These three very different presentations all likely fall under the banner of OCD but may be misinterpreted – and, therefore, wrongly treated.

As an OCD-trained clinician, there are several “pink flags” that often lead me to screen for OCD using the Yale-Brown Obsessive Compulsive Scale.  These indicators include, but are not limited to:

• A family history of OCD, Tic Disorders, chronic skin picking or hair pulling, agoraphobia, high levels of anxiety, eating disorders, or body dysmorphia. OCD and its neurological "cousins" often run in families.

• “Quirky” habits around food, cleanliness, symmetry – anything that seems like an unusual habit that someone is compelled to do and doesn’t align with reason.

• Chronic, unexplained slowness performing regular daily tasks (e.g., brushing teeth, taking showers, tying shoes).

• An experience of “getting the ick” about things that might not seem seem “icky” to others – a general sense of almost physical uneasiness or neurological sensitivity to typically neutral stimuli.

• Psychological rigidity or rigid rules in which mundane things have to be a certain way.

• Extreme perfectionism and perfectionistic paralysis.

• Extreme avoidance of essential functions or tasks. 

What is OCD, Actually?

The Diagnostic and Statistical Manual of Mental Disorders lists two primary criteria for official OCD diagnosis:

Obsessions: “Recurrent and Persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals caused by marked anxiety or distress.   

Compulsions: Repetitive behaviors or mental acts that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. 

While we all experience intrusive thoughts and some level of compulsion, a person with clinical-levels of OCD experiences significant distress and disruption to life as a result of the symptoms.  They may severely restrict their lifestyle to accommodate the anxiety, involve others in their compulsions, and spend hours engaging in rituals or finding ways to avoid uncomfortable situations.     

As mentioned above, OCD can look wildly different from one person to the next and can be expressed in each individual in an almost infinite number of theme areas.  Some of the more common subtypes of OCD are contamination, harm, checking, perfectionism, and symmetry subtypes of OCD – but there are a myriad of unique ways that OCD can be expressed in an individuals’ thought and behavior.  In my own therapy practice, I have seen the “checking” subtype range from checking stoves to “checking” whether one is existing in the same plane of reality as everyone else.      One client may express their perfectionism by obsessing for hours over the fine details of perfect handwriting or achieving straight A’s, to becoming paralyzed attempting to make exactly the right choice for a summer job or selecting the perfect word in a conversation with friends.  This wide variation is why OCD can be quite difficult to distinguish between other disorders. A trained OCD clinician is looking for these stereotypical theme areas, but also must be on the look out for the underlying process of obsession/compulsion that may not fit the typical OCD expression.   

Treatment Options

Once someone is diagnosed with OCD, the good news is that it is treatable! There are several tools that you and your treatment team can employ to help reduce the hold OCD has on your life. 

• Exposure and Response Prevention Therapy: The gold standard for OCD treatment is Exposure and Response Prevention therapy, known as ERP. ERP is a type of cognitive behavioral therapy in which you work with a trained therapist to engage in a structured set of exposures to things that make you uncomfortable or afraid. Typically, a therapist will work with you to first get a fuller understanding of how OCD sensitivities are shaping your behavior. You will then develop a “fear ladder”, which is a list of activities or situations that you will work to systematically encounter. With consistent work both in and outside of therapy, you can often habituate to the feared stimuli so that they become less frightening. If you would like to learn more, you can order The OCD Workbook: Your Guide to Breaking Free from Obsessive-Compulsive Disorder.  (https://www.amazon.com/OCD-Workbook-Breaking-Obsessive-Compulsive-Disorder/dp/1572249218/ref=bmx_dp_7kqolgrn_d_sccl_2_3/142-1178019-0352568?pd_rd_w=iyMte&content-id=amzn1.sym.088efd89-6be9-4246-acb9-556ef19cf908&pf_rd_p=088efd89-6be9-4246-acb9-556ef19cf908&pf_rd_r=S2H5HNFG2AKYZ3REK5CZ&pd_rd_wg=Nf4SI&pd_rd_r=01896a54-319e-4d76-a240-fd014a39858a&pd_rd_i=1572249218&psc=1

• Acceptance and Commitment Therapy:  For some, jumping right into ERP is just too much.  I liken it to asking someone who is afraid of spiders to willingly work towards entering a small closet full of 10,000 spiders! Even though we may know that OCD is controlling us in ways we don’t like (e.g., you really need to be able to get into that closet!), it may be difficult to convince ourselves to willingly expose our bodies and minds to such discomfort. As a result, folks sometimes talk themselves out of doing the work.

  
  

  For those of us in this camp, I highly recommend finding a clinician who is well versed in both Acceptance and Commitment Therapy (ACT) and ERP and can integrate these techniques into a single treatment plan. ACT engages the client in a more holistic approach.  Using metaphor and experiential exercises, ERP goes beyond the what by preparing us with the why and how. It helps us answer questions like: Do we really believe it is worth treating our OCD even when it’s terribly uncomfortable? If so, why? If I can’t get rid of the discomfort, is there a way to have a different, healthier relationship with the anxiety I feel in my mind and body? Once we work with our therapist to come up with our own unique answers to these questions, we then engage in some of the same types of "exposures" as we do with ERP, using each exercise as practice in living out the values we identify in the earlier work of ACT.

  
  

  For more information on ACT for OCD, see The ACT Workbook for OCD: Mindfulness, Acceptance, and Exposure Skills to Live Well with Obsessive-Compulsive Disorder.  https://www.newharbinger.com/9781684032891/the-act-workbook-for-ocd/

• Inference-Based Cognitive Behavioral Therapy (I-CBT or IBT):  I-CBT is newer on the scene, causing some healthy controversy in the field of OCD treatment. This treatment focuses primarily on challenging inaccurate beliefs underpinning the obsessions and replacing those beliefs with more accurate information. Once the foundational thoughts are challenged and replaced, clients are tasked with acting on the new information by reducing rituals and/or avoidance behaviors. While this treatment is relatively new compared to ERP and ACT, several studies have been published attesting to its effectiveness , including https://www.sciencedirect.com/science/article/abs/pii/S0165032716302130  and  https://karger.com/pps/article/91/5/348/826583/Evaluation-of-Inference-Based-Cognitive-Behavioral.

• Medication: Many people struggle to engage meaningfully in therapy for OCD due to the intensity of symptoms. Others struggle to find the time for these treatments, which require significant commitment and consistency, and still others make the commitment and just don’t make the type of headway in treatment they’d like to see. In these cases, medication is highly recommended. A psychiatrist will typically prescribe an SSRI, often at a dose much higher than typically prescribed for depression. Examples of SSRI’s include: Fluoxetine (Prozac), Citalopram (Celexa), Paroxetine (Paxil), Sertraline (Zoloft).  Consult your psychiatrist for more information!

• Warning: ERP and ACT paradigms argue that typical talk therapy can actually make things worse for those with OCD.  Most therapy modalities such as "person centered", traditional cognitive behavioral therapies, or dialectical behavioral therapy teach coping mechanisms or constructive self talk to address mental health challenges. ERP and ACT, on the other hand, ask individuals with OCD to take a "guided tour" through their fears, purposefully walking into uncomfortable situations with their defenses down so that they can experience the anxiety and habituate to it. ERP and ACT theoretical frameworks actually argue against engaging in typical talk therapy for the specific OCD symptoms (although talk therapy may be useful for other issues), purporting that engaging in reasoning exercises and/or coping skills can create a new, unhelpful rituals. In such cases, the concern is that we may find ourselves in a cycle of persistently engaging the new "skill" to neutralize the original obsession only to find that the anxiety relief is quite temporary, requiring us to repeat the process yet again.

Where can I get treatment? 

Thankfully, there are great resources for those looking to engage with a trained OCD treatment provider. Any therapist who practices ERP,  ACT with ERP, and/or I-CBT should be able to work with you on your individualized treatment plan and help get you on the road to a healthier life. I am trained in both ERP and ACT and see clients both online and in person. 

Another resource for online therapy is NOCD, which you can learn more about at www.treatmyocd.com. This service is entirely staffed by ERP trained therapists.  If you are looking for more local options in the Los Angeles area, we have a terrific resource in UCLA’s Semel Institute, which you can learn more about at https://www.semel.ucla.edu/adc/obsessive-compulsive-disorder-ocd.

As you consider entering treatment, know that this is stressful work that takes consistent commitment. It is important that you work with a practioner that you trust and enjoy, because you are going to need every incentive to return each week! So, if the first person you engage (even if it's me!) isn't working out, do yourself a favor and give someone else a try. We all have different personalities and a good therapist understands that sometimes there just isn't a great fit.

Also, the work can be pretty scary at the beginning. If you have spent years adhering to strict rules and strategically avoiding discomfort, it is likely that things that once were “anxiety producing” have now escalated to “terrifying”. Communicate with your therapist if you are feeling outside your zone of tolerance and ask to tackle an easier exposure. The important thing is that you're making some progress, no matter how small. Sometimes just showing up for therapy is an accomplishment in and of itself!

As difficult as OCD can be, the good news is that with consistent, focused treatment, there is hope! 

Where can I learn more?

The International OCD Foundation is a great place to start. You can find them at https://iocdf.org/about-ocd/. They host an annual conference for people with lived experience (that’s you!) and mental health practitioners, publish important resources, and advocate for all things OCD-related.  I also highly recommend NOCD’s website, which includes a number of short, well written articles: treatmyocd.com.

There are also some great books out there written by individuals who struggle with OCD.  On my own bookshelves, you’ll find: The Man Who Couldn’t Stop: OCD and the True Story of a Life Lost in Thought by David Adam and Turtles All the Way Down by John Green.   Other books are Is Fred in the Refrigerator? Taming OCD and Reclaiming my Life by Shala Nicely, Obsessive Intrusive Magical Thinking by Marianne Eloise,  and Just Checking: Scenes from the Life of an Obsessive Compulsive by Emily Colas.

If you are reading this article and you or someone you know is struggling with OCD, I hope you will reach out to a trained clinician for support. There is a path toward a more free and full life!