Let’s open today’s Mental Health lesson with a 35-year-old woman named Carolyn. Ever since she was a teen, Carolyn has struggled with obsessive thoughts and compulsions. In the past decade, these thoughts and behaviors have become more and more time- and thought-consuming, causing her a great deal of anxiety.

Each morning, Carolyn wakes up at 6AM. She starts each day by scrubbing her kitchen floor for exactly one hour, regardless of whether it looks dirty. Then, after two cups of coffee, Carolyn takes a forty-five minute shower, washing her hair exactly three times, conditioning it twice. On her way to work, Carolyn stops each morning at the same gas station to top off her tank, whether it needs it or not. (A friend once asked why she does this, and she explained that she has a nagging fear of what would happen if she were to run out of gas on her way to work … Not that her tank has ever been close to E.)

In recent months, Carolyn has received many complaints from her supervisor about the timeliness of her task completions. In checking and rechecking her work (“Just to make sure there are no mistakes,” she says), it takes her twice as long to complete basic paperwork. Despite her best efforts to speed up her process, Carolyn cannot relax unless she has checked her work at least three times. She keeps fretting over what would happen if she were to make a stupid mistake and destroy the company through her carelessness.

In the evenings, Carolyn often completes her route between work and home three to five times. This started several months ago, when she hit a speedbump unexpectedly and it occurred to her how easily she could accidentally run someone over in the middle of the night, in the dark. Since then, she cannot stop thinking about the person she “might have hit” unless she drives the route three to five times in search of them, just to be absolutely sure she didn’t hurt anyone.

When she goes to bed at exactly 9PM, Carolyn says anywhere from three to twenty prayers. She must be absolutely certain she has prayed for everyone she cares about before she goes to sleep, to make sure nothing bad will happen to them before morning.

This, in a nutshell, is Carolyn’s routine from morning to night. She realizes that some of her thoughts and behaviors aren’t exactly “rational,” but she doesn’t know how to control or stop them. The obsessions and compulsions are taking a large amount of time, interfering with her ability to complete work tasks, to socialize, and to live a normal, low-stress life. What can she do?

What Exactly Is Obsessive-Compulsive Disorder?

Obviously, based on her many symptoms, Carolyn is suffering from Obsessive-Compulsive Disorder, commonly known as OCD. What exactly is this illness?

It might be best to start with what OCD is NOT. First and foremost, OCD is not a cutesy adjective to use when someone likes to color-coordinate their clothes or keeps to a rigorous cleaning schedule. (“Haha! I’m so OCD!”) In fact, many people who suffer from this mental disorder find these comments offensive. So… you’ve been warned.

Now that we’ve gotten that out of the way… OCD is a mental illness that falls under the broader category of “Obsessive-Compulsive and Related Disorders” in the DSM-5. It affects 2-3% of people in the United States, often beginning in childhood, adolescence, or early adulthood (“What Is Obsessive-Compulsive Disorder?” 2020). It is characterized by the presence of obsessions, compulsions, or both.

Obsessions

Obsessions are defined as recurrent or persistent thoughts, urges, or images that are unwanted or intrusive, causing the person anxiety or distress (American Psychiatric Association, 2013). The person experiencing them tries to ignore these obsessions, or performs a compulsive act in order to neutralize them (American Psychiatric Association, 2013). (For example, Carolyn’s intrusive thought about submitting imperfect work that will destroy her company is an obsession.)

Compulsions

Compulsions are defined as repetitive, rigid behaviors a person is driven to perform in response to an obsession (American Psychiatric Association, 2013). These acts are meant to prevent or reduce the anxiety caused by obsessions, or to prevent a dreaded event from happening (American Psychiatric Association, 2013). The behaviors are either not connected in a realistic way to what they are meant to prevent or are clearly excessive (American Psychiatric Association, 2013). (For example, Carolyn’s need to recheck her work multiple times to prevent imperfections that would destroy the company is a compulsion.)

In order to receive a diagnosis of OCD, the obsessions and compulsions must be time-consuming, taking up over an hour per day, or cause significant distress or troubles in social settings, work, or other important areas of life functioning (American Psychiatric Association, 2013). The symptoms are not the result of medication or substance use and are not better explained by other mental disorders (American Psychiatric Association, 2013).

Like Carolyn, many who suffer from OCD are completely aware that their obsessions and compulsions are irrational or inaccurate, but still struggle to control the beliefs or behaviors. Such people would be diagnosed with OCD “with good or fair insight” (American Psychiatric Association, 2013). Others recognize that their obsessive-compulsive beliefs are probably not accurate (“with poor insight”), while others are completely convinced that their obsessive-compulsive beliefs are true (“with absent insight/delusional beliefs) (American Psychiatric Association, 2013). When working with someone who struggles with OCD, mental health professionals must determine the level of the person’s insight in making a diagnosis.

This focus on insight really speaks to the difficulty of the illness, in terms of controlling behaviors and thoughts. It is important to realize that people struggling with OCD often realize that their thoughts and behaviors are not, strictly speaking, “rational”. Curing the illness is not simply a matter of bringing the irrationality of their thoughts/actions to their attention. (“Oh, REALLY? You mean if I don’t check the stove 25 times before I leave, the house probably won’t burn down? Golly gee whiz, thanks for letting me know! NOW I’M CURED!”) In fact, continually reminding sufferers of how “silly” their beliefs/actions are will probably do more harm than good, making the person feel misunderstood, invalidated, and judged, which is never helpful for anyone, regardless of the disorder.

OCD Treatment: Exposure and Response Prevention

In order to help someone struggling with OCD, compassion and patience are key. This is a stubborn, debilitating mental disorder that takes a great deal of time and effort to overcome.

There are a variety of treatment options available, including medication and psychotherapy. One of the most popular treatments is the Cognitive Behavior Therapy technique known as Exposure and Response Prevention (ERP). With ERP, clients and therapists work together to form an exposure plan. The “exposure” in ERP involves exposing the client to thoughts, images, objects and situations that trigger OCD-related obsessions (“Exposure and Response Prevention (ERP),” n.d.). The “response prevention” involves avoiding the compulsive behaviors or rituals that must be completed once the obsession is triggered (“Exposure and Response Prevention (ERP),” n.d.). The behavior avoidance is likely to cause the client a great deal of stress, especially at the beginning of treatment. It is important for the therapist to be involved to guide the ERP process during this time (“Exposure and Response Prevention (ERP),” n.d.). With ERP, clients usually start with small changes, gradually increasing as the client learns to cope with his anxiety levels. The idea behind ERP is that, as clients force themselves to confront their obsessions without relying on compulsive behaviors to lower their distress, the obsessions will diminish, eventually disappearing. In a way, it’s similar to standing up to a bully who demands your lunch money. The more you give in to the bully’s (in this case, the obsession’s) demands, the stronger the bully becomes. The more you are able to hold out, or confront the bully head on, the less power the bully holds over you.

Let’s return to Carolyn. One of her many obsessions involves driving back and forth from work to her house several times per night, “just in case she hit someone.” The bully in her head (the obsession) will not allow her to relax until she makes sure nobody was hurt. Driving her route several times is the compulsive behavior (basically, handing over her lunch money to the bully). If a therapist were to use ERP with Carolyn, they would create a plan for gradually preventing the compulsive behavior in response to the obsession. So if Carolyn was driving her route three to five times, she might reduce this number to two to three times. This reduction will initially cause her great distress, as the “bully” won’t like that she is trying to stand up to it. With time, as she comes to see that the obsessions lessen without the compulsive behavior, she will reduce her trips to one to two times per night, eventually not performing the compulsive behavior at all.

In Conclusion

OCD is no joke. For many, the symptoms cause them to feel imprisoned in a mental cage, controlled by a highly demanding, rigid, cruel dictator that will not allow them to rest until they have humored the dictator’s every whim. It is not a matter of logically “thinking away” the disease. (Although, as ERP proves, the more one exposes himself to the discomfort of “standing up to the bully,” the more clearly he sees the lack of power the bully really holds in a rational world.) So when you meet someone who struggles with OCD, always remember to be kind and nonjudgmental. Only with a great deal of time, patience, and courage will one find the means of taking back control of his or her life, putting the OCD bully in its place, once and for all.

Courtesy: Gwendolyn Brown, M.S..

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