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Dirty Hands

Obsessive-Compulsive Disorder (OCD)

OCD is an extremely challenging condition to live with. It’s certainly not a quirk, and it’s not about liking things tidy. It’s like having a smartphone app that’s meant to alert you to important tasks or dangers, but malfunctions and instead sends repetitive notifications, usually for no reason and often with disturbing or irrelevant content. These notifications are like the intrusive thoughts/images that become problematic in OCD.

 

But it gets worse. Even though you know the app is glitchy, you can’t turn off the

notifications and you can’t ignore them; the more you try, the more notifications come through. Moreover, you feel compelled to check the notifications every time, just in case… This takes time, costs energy, and stops you from getting on with life.

 

The good news is, the app can be fixed. That’s where CBT (with an emphasis on Exposure and Response Prevention) comes in.

Overview

OCD is usually characterised by persistent, unwanted thoughts (obsessions) and/or repetitive behaviours (compulsions). 

 

Obsessions are unwanted thoughts, images, or impulses that the person experiencing them finds disturbing. They feel beyond the person's control and, often to their frustration, they are recognised as being unrealistic and at times completely irrational.

Accordingly, they tend to bring about feelings of anxiety characterised by extreme uncertainty about whatever it is that they are preoccupied. For some, the predominant emotional response is disgust rather than anxiety, but either way it is not unusual to eventually experience depressed mood.

Compulsions are the responses people with OCD feel they must do in order to resolve their obsession, though inevitably these compulsive responses tend only to perpetuate their preoccupation.

The vast majority of people with OCD recognise that there obsessions aren't true and that their compulsive behaviours are excessive, but nevertheless they have significant difficulties disengaging from their thoughts and stopping their behaviours.

OCD subtypes

There are several subtypes of OCD, the most common of which are included below:

1. Contamination/washing: characterised by an excessive and unrealistic fear of contamination, which might be from dirt, germs, disease, bodily fluids, disease, toxins, or other sources. People with this type of OCD tend to engage in excessive cleaning, hand washing, and other avoidant behaviours.

2. Sexual obsessions: characterised by unwanted thoughts/images of a sexual nature. These thoughts can become terrifying for the person with OCD, as the content can be to them abhorrent. Common sexual obsessions noted in OCD include fears of sexually harming or having attraction to children, family members, genders not congruent with their genuine sexual preference, animals, or others. 

3. Violent obsessions: characterised by unwanted thoughts/images relevant to harming oneself or harming others, and fears of having urges therein. Often people with violent obsessions will avoid objects or situations they feel might put them at risk of these unwanted thoughts/feelings/urges (e.g., cutlery, heights, being alone with others)

4. Responsibility obsessions: characterised by an excessive fear of being responsible for catastrophe, such as fire, break-ins, motor vehicle accidents). This obsession is usually accompanied by excessive checking behaviour (e.g., locks, switches, rearview mirror).

5. Religious obsessions (scrupulosity): characterised by a fear of offending or harming figures of religious significance, usually a god or gods. Typically this involves an excessive concern about blasphemy, and can be accompanied by excessive use of religious practices/rituals in a manner not necessarily in keeping with their beliefs.

6. 'Just Right' or perfectionism related obsessions: characterised by obsessions around precision, evenness, 'correct' performance of activities, and so forth. 

7. Relationship obsessions: characterised by excessive and unhealthy preoccupation with the adequacy of their relationship or the qualities of their partner. This usually involves hyperfocus on perceived flaws and damaging reassurance seeking behaviour.

8. The Rest! Unfortunately, OCD can latch itself onto just about anything. Other domains might include existential matters, bodily feelings, and emotional experiences, though this list s not exhaustive. 

OCD Treatment

The gold standard treatment for OCD is Cognitive Behavioural Therapy (CBT), with an emphasis on Exposure and Response Prevention (ERP) strategies. For some people, medication will be an important part of treatment, in conjunction with CBT.

Exposure and Response Prevention

Chances are that you are on this page because you might have googled ERP - please be assured that our Penrith Clinical Psychologists have significant experience in applying ERP, and we are comfortable tailoring it to each individual's presenting needs. 

 

Exposure in ERP involves gradually facing the thoughts/images (and items/situations relevant to those thoughts/images) that provoke obsessions. 

 

Response Prevention involves choosing to refrain from engaging in a compulsive behaviour once the obsession has been confronted.

How does it work?

To some, the idea of deliberately exposing themselves to things they know are going to provoke their anxiety sounds too hard, or at the very least a little odd. Usually people report that they have encountered or confronted the content of their obsession and it resulted simply in them becoming more anxious.

The truth is that ERP can be quite challenging. But when it is done correctly and under the guidance of a Clinical Psychologist experienced in its appropriate delivery, it can bring about immense positive change.

 

Usually what happens upon commencing ERP is that anxiety will increase. But upon staying with the intrusive thoughts/images rather than escaping or engaging in unhelpful compulsive responses, evidence becomes available that the thoughts/images and associated feelings have no other effect. That is, they bring about anxiety, but there are no other consequences – they can't harm you.

Upon this, and a decision to eliminate efforts to resist the obsessions and associated anxiety, the discomfort begins to reduce. We call this habituation, and Exposure continues until this is achieved. Almost without fail, people habituate far more rapidly than they anticipate. With repeated ERP, they not only become less troubled by thoughts/images, but they also become more able to reengage in a healthy, balanced life.

This process will be undertaken following a detailed assessment to ensure that the ERP program is relevant specifically to your needs. Usually a 'hierarchy' of exposure targets will be collaborated upon, so you can build confidence by initially targeting relatively lower level obsessional thoughts/images. 

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