Obsessive Compulsive Disorder: Identification and Self-Help Strategies

Identification: Obsessive Compulsive Disorder (OCD) is an anxiety related problem which affects approximately 2.5% of students on campus. OCD can take a variety of forms and can significantly affect a persons day to day enjoyment of life. Before we go any further, lets define what obsessions and compulsions are, and distinguish an obsession from regular worries. Obsession: repeated and persistent thoughts, images and impulses which are distressing, frightening or shame producing (i.e., fear that you are going to be contaminated by touching a doorknob; repeated images of having sex with one of your parents; repeated thoughts that you may be gay, when in fact there is no evidence for this). Compulsion: thoughts, images or actions that are used to reduce the anxiety that is created by the obsession (i.e., washing your hands repeatedly when they are not dirty; repeating a series of numbers in your head for no apparent reason; ordering everything in your room in an exact alignment). Regular Worries: thoughts that create anxiety and distress, but change a lot from day to day (i.e., concerns you are not adequately prepared for an upcoming exam; fears that your friend no longer wants to hang out with you; worries that you wont find a job after graduation). It is important to understand the relationship between obsessions and compulsions, because they feed into each other and create a vicious anxiety-provoking cycle. OCD Cycle Trigger (event, situation) Obsession (repeated thought, image or impulse) Distress (anxiety, shame, fear) Compulsion (thought, image or action to reduce the distress) Anxiety Reduction (which reinforces the compulsion)

People with obsessions and compulsions tend to fit in one or more of the following categories.

Types of OCD 1. Washers and Cleaners This obsession involves being consumed with thoughts about being contaminated by either objects or situations. Potential contaminants include germs, diseases, chemicals or secretions. To alleviate this form of contamination, people develop some type of ritualized behavior such as washing ones hands excessively, cleaning ones house for hours a day, or taking extremely long showers. These rituals vary in length and can take up to 10 hours per day to perform. 2. Orderers People who fit this category are compelled to keep things in a very rigid order, or some type of symmetrical pattern, otherwise they feel a real sense of distress. This can involve ordering or aligning everything on their desk or in their room, feeling the need to make their bed in an impeccable fashion, or finding the right place for all of their belongings. 3. Checkers This category of OCD involves checking repeatedly to ensure that something terrible is prevented. This could involve checking windows and doors to avoid a break-in, checking stoves or other appliances to prevent a fire, or checking excessively to ensure that mistakes or errors are not made. This often involves checking, doubting the results of the check and then re-checking again, and again. 4. Repeaters Repeaters feel a strong urge to repeat an action to prevent a fearful thought from coming true, such as some catastrophe. Unlike checkers, however, they cannot see a logical connection between the obsession and compulsion. Instead, the ritual has a magical connection to the obsessional thoughts. 5. Hoarders This involves feeling a need to hold on to very trivial or often useless objects, to the extent of filling up ones house with these objects. This could include hoarding almost anything, such as old newspapers, magazines, books, paper, receipts, etc. The biggest fear for hoarders is that someone will disrupt their collections, or that they wont be able to find something at the moment they need it. 6. Thinking Ritualizers Thinking ritualizers do not have behavioral rituals to reduce their anxiety, but instead utilize mental routines to get relief. This can involve repeating certain numbers or words in ones head, praying for non-religious reasons, thinking of good thoughts to replace bad thoughts, or by making mental lists to prevent a negative outcome of some kind. -2-

7. Pure Obsessionals With pure obsessions, people repeatedly worry about something that is uncontrollable and often very upsetting, but do not have any behavioral rituals to reduce their anxiety. For example, they may have images of some type of inappropriate sexual behavior, such as having sex with their parents, or a strong impulse to hurt or kill someone they know or love. These thoughts are often accompanied with high levels of shame and they can feel as guilty as if they had actually done the acts.

Strategies: 1. Monitor Both Your Obsessions and Compulsions It is difficult to reduce or minimize your OCD until you are aware of the nature of your obsessions and compulsions. Toward this end, it can be helpful to develop an OCD monitoring form similar to the one below:
Situation/Trigger Touching the door on a public washroom. Obsession That door is covered with germs. Im going to get sick or I might die. Feelings (0-10) Fear (9) Anxiety (8) Faulty Belief Touching almost anything is highly risky. I need to constantly protect myself. Compulsions/Coping Strategy Washed hands repeatedly for 10 minutes, until my hands were red.

Use the monitoring form each day for 1 week or on specific days over the course of several weeks to collect information to guide you in better managing your OCD. 2. Determine Which Categories Your OCD Symptoms Fall Under By referring back to the identification section of this handout, it can be very helpful to determine whether your OCD symptoms fit under one or more of the categories that were previously described. These include: washers and cleaners, orderers, checkers, repeaters, hoarders, thinking ritualizers, and pure obsessionals. Your OCD Monitoring Form should help in this process. This will help you further understand the nature of your obsessions and compulsions. 3. Decide Whether You Need Additional Assistance Depending on the severity of your symptoms and the amount it disrupts your life, you may benefit from additional assistance, either from a psychologist or a physician. A psychologist can help you work through some of the strategies and give you support. A physician can prescribe some medications if your symptoms are severe or resistant to the self-help strategies. Never use medications in the absence of the self-help strategies, since it is highly likely that the OCD will come back whenever you stop taking the medications.

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4. Understand The Irrational Nature Of Your Obsessions Remind yourself that your obsessions are unrealistic, exaggerated or irrational. This is why it is possible to overcome the obsessions, because they have little or no truth in reality, even though your fears may seem very real to you. Research shows that all people have thoughts, images or impulses that may be distressing (i.e., the image of hitting someone with your car). However, the difference between someone with OCD and the average person is that when you have OCD, you see the thoughts as meaningful, important or dangerous, rather than random and harmless. By overvaluing the thought, the thought gains power and tends to reoccur. 5. Relabel Your Thoughts and Behaviors Relabel your distressing thoughts and unusual behaviors, and call them what they really are obsessions and compulsions. By relabeling, you will be much better able to see the thoughts as faulty rather than accurate. You will also be less likely to need your compulsions if you dont believe the thoughts, or see them as simply an aspect of your OCD. Its important to say to yourself, This isnt me its my OCD or My OCD brain is sending false messages. You need to avoid being tricked into believing that the feeling that you need to ritualize is a real need, since it isnt; or that the obsessive thought is valid, because its not. 6. Develop an Anxiety Hierarchy Exposure and ritual prevention (ERP) is the cognitive-behavioral technique which is most effective in reducing both obsessions and compulsions. It often involves first developing an anxiety hierarchy. Here is an example of a typical anxiety hierarchy for someone who has fears about being contaminated. The rating on the side refers to the amount of distress someone feels when exposed to the trigger, on a scale of 0 to 100. These are referred to as Subjective Units of Distress (SUDS). Trigger 1. 2. 3. 4. 5. 6. 7. 8. Touching dirty mail Wearing contaminated clothing Touching ones own face Touching a doorknob at home Handling raw meat Touching a doorknob in a public building Sitting in a doctors office Touching a faucet in a public washroom SUDS Level (0-100) 10 20 30 40 50 60 70 80 90 100 -4-

9. Sitting next to someone who is sick 10. Touching a toilet seat

For each situation or trigger, you would rate what you think you would feel if you did not use your compulsion to manage the anxiety or fear. 7. Expose Yourself To The Anxiety Triggers Once you have developed the hierarchy, begin exposing yourself to the items on the list which are less anxiety-provoking, but still cause a moderate level of distress. Exposure means, for example, deliberately touching contaminated objects, deliberately thinking about disturbing thoughts, or leaving household objects in an imperfect order. Do not try to distract yourself from the anxiety, but instead simply focus on the distress and over time a process of habitation will occur, where the trigger will become less distressing. Expect to experience high levels of anxiety when you first do the exposure, but with time this will come down. During exposure, do not seek reassurance from others that it will be O.K., develop new rituals to neutralize the anxiety, or allow yourself to dissociate (tune out) from the exposure experience. Each of these choices will reduce the power of the exposure technique. 8. Do Not Try To Stop The Thoughts Do not try to stop the obsessive thoughts in their tracks. This will only lead to more stress, frustration and disappointment. Instead, accept the presence of the thoughts, without believing the content of the thoughts. The more we try to directly suppress thoughts, the more the thoughts will return in our minds. Using exposure and response prevention over the course of weeks or months, the thoughts will decrease in intensity and eventually disappear. 9. Change Your Obsession As a step toward letting go of your obsessions, it is sometimes easier to start by changing your obsession in some way. Change the way you obsess by one of several alternatives: a) Write out your obsessive worries by writing out the obsession each time you have one, you begin to see how repetitive and unrealistic it is. Over time, obsessing will become just too much work to do. b) Sing your obsession by singing your obsessive thoughts, you will immediately find they are less distressing. It is hard to take something too seriously if you are singing it. This, of course, will work with obsessive thoughts, not with images or impulses. c) Change the image in the case that the obsession is of a distressing image, it can be very helpful to develop a new or altered image. You can use your creativity to develop an image that is more relaxing or perhaps humorous. d) Postpone attending to the obsessions - Postpone attending to your obsession for a specified period of time. In this way you are not resisting the obsession, but are beginning to bring it under conscious control. At first, try to postpone attending to the obsession only for a few minutes. Later you can extend this period. When the time to -5-

obsess arrives, you can choose to either attend to it or postpone again. Continue to extend the time you postpone until you are able to do it for a few hours. 10. Practice Ritual Prevention While doing exposure, you also have to practice ritual or response prevention. This means you stop using your compulsive behaviors or rituals to reduce your anxiety. Ideally, you would immediately end all rituals or compulsions as soon as you begin the exposure, but in reality, you may need to slowly reduce the compulsions or change the compulsion in some way. It is important to remember that no one has ever gone crazy or died from the anxiety created by exposure and ritual prevention. It just feels very uncomfortable. If you bear with the anxiety, it will decrease over time. In order to be successful with ERP, you need extensive and prolonged contact with the obsessive triggers and elimination of the rituals used to reduce the anxiety. Ideally, you should work on your exposures at least once a day and repeat the exposure until the triggering event becomes manageable, then move to the next item on the hierarchy. In deciding on goals for reduction of your rituals (i.e., hand-washing, checking stoves or doors, taking a shower, etc.), always think about what the average person would do. For example, the average person might wash their hands for less than 30 seconds prior to a meal, or after going to the toilet, or after touching something that is visibly dirty. This should become the goal in terms of determining the frequency of the ritualistic behavior. For checking, the average person would likely check a door, window or appliance one time and this would become your goal. 11. Change Your Ritual Rather than simply stopping your compulsions immediately, it might be easier to try one, or a combination, of the following strategies: a) Postpone Ritualizing start with short periods where you postpone doing the ritual/compulsion and then progressively increase the length of time. For example, if you are a washer, it could mean delaying hand washing for successively longer periods (Immediately 2 minutes 5 minutes 10 minutes 30 minutes, etc.) b) Ritualize In Slow Motion this means doing the ritual, but at a much slower pace than you usually would. If the ritual took 1 minute previously, do the ritual so slowly that it takes 5 minutes, for example. c) Change The Way You Ritualize by analyzing the details of the ritual, you will be able to change certain aspects of it, such as the order in which you do the ritual, the frequency of the ritual, the objects you use for the ritual or the location with which you complete the ritual. d) Add An Additional Component To The Ritual try to make this additional task, or consequence, unrelated to the ritual and something that significantly interferes with your -6-

normal routine. This will both significantly increase your awareness of the ritual and make doing it very cumbersome, and therefore easier to stop in the long-term. 12. Imaginal Exposure ERP works great for fears and worries where you are able to confront situations in real life. However, there are a number of situations that are difficult or impossible to face and utilize ERP. For these situations (i.e. thoughts of having sex with Jesus, obsessive fears of contacting AIDS, fears that bugs are invading your ears), a different form of exposure is required. The idea behind imaginal exposure is to arrange opportunities to habituate to your own thoughts. Rather than trying to stop the obsessive thought, image or impulse, allow yourself to have the thought without judging it. By accepting, rather than struggling to get rid of your obsessions, you will be reducing the urge to ritualize. By directly trying to stop the obsessions, the obsessions actually gain strength. By choosing to have them, you immediately gain some control over them. Exposure can occur in two steps: a) Write out a complete description of the obsessive thoughts or fears, particularly on what would happen if you didnt use your rituals (3-5 minutes long). b) Record the description on a tape and play it repeatedly for at least 45 minutes per day until the image no longer evokes significant anxiety. If these images are too frightening to use for the exposure, you may have to modify or shorten the description at first. If they dont arouse a lot of anxiety, you may need to make them more graphic. Also, if you have a strong belief the images are really true, have a diagnosis of borderline personality disorder or a history of psychosis, you may need supervision by a therapist before using this form of exposure. 13. Become Aware Of Your Faulty Beliefs If you have OCD, you probably also have a set of unhelpful and often irrational beliefs about the likelihood of danger in many different situations. It is these faulty beliefs that in turn create a lot of the anxiety and fear in people with OCD. Here are some examples of typical faulty beliefs: a) Magical Thinking believing that simply having a thought increases the likelihood that something terrible will happen. b) Intolerance of Uncertainty believing that if you are not 100% certain of something it is intolerable.

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c) Over-responsibility believing that if anything bad happens to yourself or others, then you are 100% responsible. d) Over-Control believing that you must maintain complete control over your thoughts and behaviors at all times or it is intolerable and will have dire consequences. e) Overestimating Harm/Danger believing that even the slightest chance of something bad happening is the same as there being 100% certainty. f) Perfectionism believing that you need to do something perfectly, or bad things will happen to either yourself or the ones you love. g) Persistent Doubting being uncertain about whether you did something (i.e., checked a door, hurt someone) even when there is no basis for your doubts. h) Intolerance of Anxiety believing that you are unable to handle even the slightest anxiety and feeling like you need to do anything to eliminate it. i) Pessimistic Bias believing that if anything is going to go wrong, it is going to happen to you. j) Extraordinary Cause and Effect believing that objects are able to defy the laws of nature (i.e., germs can leap tall buildings, stoves can magically turn on, doors can spontaneously unlock). 14. Change Your Faulty Beliefs Using An Anxiety Log To change your faulty beliefs, it can be helpful to create a chart similar to the following:
Negative Automatic Thoughts This door may be contaminated. I may get sick and even die.

Triggering Event Touching a well used doorknob in a public building.

Faulty Beliefs

Evidence (for and against the belief)

Realistic Coping Statements Ive never died from touching a doorknob yet. This is just my OCD talking.

Overestimating There is no evidence I harm/danger will get sick or die if I touch a doorknob. Ive been sick before but Im unsure what caused it.

Begin to use this chart whenever your anxiety related to your obsessions increases significantly. When you utilize the chart, make sure you are not just using positive thinking to alter your faulty beliefs. Make your thinking more realistic by looking at the evidence for and against the belief. Remember also that there may be more than one faulty belief affecting your thinking. Once you have developed some realistic coping statements, repeat them over and over in your head to correct your thinking. Repeated practice will break down the faulty beliefs over time. -8-

15. Challenge Your Faulty Beliefs By Looking At Probabilities Challenge the meaning you give the thought by asking yourself some of the following questions: a) Is there a 100% chance that my worst fears will happen? b) Are my concerns a reflection of the facts or just my feelings? c) Am I confusing thoughts with facts? d) What is the evidence this thought is true? e) What would I say to someone else who has this same fear? For some obsessions, it is possible to calculate the likelihood of the obsession coming true. By multiplying out the probabilities at each stage of the worry, it is possible to come up with an overall estimate of the likelihood that the obsession will come true. For example, if you were worried obsessively about leaving your iron on and your house burning down, you might do the following calculation: Event Iron is left on Iron ignites the ironing board Ironing board ignites the floor or ceiling Smoke alarm fails to go off You are unable to put out the fire Fire department fails to arrive in time Chance 10% 1% 1% 1% 50% 10% Overall Chance 10% .1% .001% .00001% .000005% .0000005%

By calculating the real risk (i.e. .0000005%), you are much better able to challenge your belief that you will be responsible for burning your house down, if you dont constantly check your iron. You can apply this same strategy for many obsessive worries and begin to break down the belief system. 16. Do Not Seek Out Help For Your Rituals Many people with OCD actually seek out help from those around them to assist in their rituals. For example, checkers may get other people in their family to repeatedly check doors, windows or stoves for them to relieve their anxiety. Washers will ask family members -9-

to do some of their rituals to keep their environment excessively clean. OCD sufferers will also repeatedly seek out reassurance, in terms of verbal feedback to alleviate their fears. It is important that you have a discussion with your family or loved ones, letting them know that you no longer want them to give reassurance, assist in your rituals, or do them for you. Try to explain to them how their help has been appreciated, but that it ultimately only feeds negatively into the OCD cycle, which you are wanting to change. 17. Keep A Journal It can be very helpful to keep a journal (written record) of your successes, managing your OCD. This will help you remember your successful attempts and build your confidence in taking control of this disorder. Do not record failed attempts, since you will likely tend to focus on these anyway, and they do not encourage you to keep up the battle. You can refer to the record anytime you feel stuck or have any sense of discouragement.

References Foa, E. & Wilson, R. (1991). Stop obsessing: How to overcome your obsessions and compulsions. New York: Bantam Books. Hyman, B.M. & Pedrick, C. (1999). The OCD workbook: Your guide to breaking free from obsessive-compulsive disorder. Oakland, CA: New Harbinger Publications. Schwartz, J.M. (1996). Brain lock: Free yourself from obsessive-compulsive behavior. New York: Harper Collins.

Written by Dr. Kim Maertz Mental Health Centre University of Alberta

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