Obsessive Compulsive Disorder (OCD) is a mental health disorder that occurs when a person gets caught in a cycle of obsessions and compulsions that negatively impacts their life. Obsessions trigger anxiety, “not right” feelings, or disgust. Compulsions can be mental or behavioral actions performed to avoid the distress triggered by obsessions.
OCD comes in different symptom subsets. Some of these subsets are familiar to many people, while others are less common and sometimes less recognizable as OCD. Some OCD symptom subsets are:
Washing - Perhaps the most commonly known subset. Obsessions are associated with becoming contaminated or in some way dirty from sources such as bodily fluids or solids, but can have an unusual twist. For example, another person may be perceived as contaminated, not because of the germs that might be on that person, but because that person is who they are. The person with OCD might think, "If I come into contact with that person, something bad will happen," or, "I will become that person," or, "I will take on [characteristics] of that person." These obsessions result in the same avoidance and/or compulsive washing rituals as with the standard contamination fears.
Cleaning is related to washing, but the focus for the person with OCD is not as much one's body as a thing or a place, such as a bathroom. The place or thing needs to be avoided or thoroughly washed, often in a ritualistic way, before the person with OCD will come in contact with it.
Checking - One of the well-known OCD presentations, but in addition to making sure that the locks are locked, the gas range or iron is off, other, more subtle forms of checking exist. This is often in the form of repeated questions, and can be anything from, "Do you think I look OK?" to "Are you sure it is safe?" Any repeated attempt to seek reassurance from another person is in fact a form of checking.
Repeating - While not a major subset, repeating can be a result of a specific obsession: "I thought the word 'hate' to myself while I walked through the doorway, so now I have to go back through it and repeat the behavior while thinking the word 'love' in order to 'erase' or 'undo' the previous activity." It can also be an attempt to ward off a bad feeling: "I need to repeat standing up and sitting down until it feels 'just right' and then I can stay seated."
Hit and Run - Also called Motor Vehicle Accident (MVA) OCD, is a specific instance of a checking behavior, which is so common that it warrants being mentioned separately. Drivers obsess that maybe they hit someone without realizing it, then drive back repeatedly to check the area for bodies and/or police or ambulance activity. They will then go home and check the news for stories about hit-and-run accidents. People with it tend not to focus so much on whether they actually killed somebody, but more on whether or not they will be caught, punished, and publicly humiliated.
Orderliness - involves things having to be exactly in their place, facing in a particular direction, or a specific distance from another object.
Need for Symmetry - The need for things to be equal, or equally weighted. For example, the glasses in a cupboard must be perfectly ordered from tallest in the center and graduated to the shortest on the outer ends. Placing glasses in this way alone is not OCD, but obsessing and being unable to leave the glasses alone, often taking an undue amount of time, maybe even making someone late for work, and even then not feeling satisfied and wanting to go back and measure/place over again, would likely be OCD.
Sexual Obsessions - Most commonly a fear that one is really gay or a pedophile when there has been no sexual arousal, fantasies, or behaviors that would support this. More common than you might imagine, it sometimes will take a while for a person with OCD or family members to recognize that this problem is in fact an OCD subset and not a struggle with sexual identity or sexual perversion.
Fear of Loss of Impulse Control - This involves the obsession that one will act out in some way, temporarily "go insane", then "snap out of it" and be stuck with the consequences of their actions. Common presentations include fear of: stabbing one's family members, blurting out inappropriate statements or curse words in public, jumping out of a moving car, or stealing something from a store. Avoidance of potentially dangerous or embarrassing situations is usually the response, or else engaging in some kind of safety behavior, such as hiding/locking up kitchen knives or going places with a trusted person who will "keep an eye" on the person.
Other subsets exist as well, such as hypochondriasis and scrupulosity. The themes are always the same, however: a sense of uncertainty or incompleteness that needs to be righted in some way is the obsessive experience. This results in a compulsive or avoidant mental action or behavior designed to avert a danger or allow for normal functioning to return (Weg, 2011).
ERP for OCD
Some people think they know what Exposure and Response Prevention (ERP) is, and to a degree, they do: For washing, expose yourself to "contaminated" things and then don't wash. For checking, when you get the urge to check something, don't. Simple in concept but challenging in execution, ERP may be partially defined by the above, but the definition doesn't really explain how to do this. Hierarchy exposure, going from easier to harder exposures, is used by many professionals as an intervention. For instance, touch the chair which is less "contaminated" first, and then work your way up to the bathroom doorknob. But this still doesn't completely define the protocol. Exposure has rules that should be followed to ensure success, and should be applied within every exposure experience. Below are some of those rules:
Frequency - Whatever you expose yourself to, and at whatever level you are in your hierarchy, it is essential that you engage in that exposure behavior frequently and regularly. It likely won’t be enough to practice leaving the house without checking the stove, or not washing your hands after touching the phone, only once a week or even once a day. These exposures have to be done frequently, often many times a day, to allow exposure to properly have its effect of desensitization.
Duration – The amount of time you expose yourself goes hand in hand with how often you do exposure. A good guide is to engage in the exposure experience until your anxiety drops to at least 50% of what it was at the very beginning of the exposure experience. This gives you the time necessary to experience desensitization. If you leave too early, you are actually reinforcing the "escape" response and training yourself to run from the anxiety, which strengthens OCD. Give yourself plenty of time whenever you engage in an exposure exercise - it is an essential part of applying the technique successfully. Rather than letting the clock tell you when you are done, let your anxiety be your guide. When it has dropped by about half, your exposure will have an effect.
Intensity - How strong of an exposure experience should you be looking for? If you start too low on your intensity level and expose yourself to a thing or situation which does not create much anxiety (say, a 2 on a 1-10 scale, where 10 is the highest imaginable anxiety), you won't get much payoff from the experience. On the other hand, biting off more than you can chew (going for a 9 or 10 right away), may feel so overwhelming that you may decide to give up the whole effort and drop out of therapy or just stop trying on your own. Aim for something between 4 and 7, and shoot for dropping it down to a 2 by the end of exposure (not zero), before moving to the next level.
Methodology - There are many ways to manipulate the intensity depending on the methodology you use. Say the challenge is to leave the house without checking that the range is on. If you presently have a ritual of touching the range knobs a certain number of times and/or in a certain order, you might first change the order, the number of times you touch them (sometimes even changing to 5 if you always have to check an even number of times), or a combination of the two. Then you can graduate to shortening the amount of time you touch them, just waving your hand across the burners as a check, and then just visually inspecting them. Next, look at them for shorter periods of time, and from further distances from the range. In all these ways, you are constantly "pushing against" the OCD, loosening its grip on you, and strengthening yourself.
Monitoring - Observing, recording, and reporting your progress to your therapist is an essential aspect of ERP. Nothing helps motivate, encourage, and clarify the progress that has already been made than good record keeping.
Postponement – Also known as "delay." Here, the focus is on when you do it. Say I expose myself to a contamination source, and my standard response is to take a ritualized two hour shower where I repeat certain behaviors and feel compelled to follow some very specific rules. In postponement, you might practice jumping into the shower for a quick rinse and then out again in just 30 seconds, drying yourself off, and then go right back in and take your two hour shower - no other changes. It is less difficult to do this when you have every intention of going right back in the shower and engaging in your full ritual. Next time you would do the same thing again, but wait 60 seconds after drying off from your 30 second rinse before beginning your two hour ritual. Next time you wait two minutes before going back in, then work yourself up to 10 or 30 minutes, or even a few hours. You eventually find that you don't feel the need to go back at all. During this process, you could experiment with adding a few seconds and a few actual washing activities to the original 30 second rinse.
We do the same kind of thing with checking the doors at bed time. Get into bed first with the lights off. Wait 10 seconds before you do your door checking ritual. Wait 30 seconds the next night, and so on.
Cognitive - Perhaps the most overlooked is the cognitive part of the exposure. Too often when people do exposure and then don't wash or check they reassure themselves mentally that everything is OK. This does not help the process. It is critical to perform cognitive exposure as well as behavioral. The person should be thinking, "Yes, I didn't check the locks and burglars are going to come into the house, steal everything, and destroy the house," repeating this over and over again on purpose, ultimately eliciting desensitization. This concept gets a little tricky, and sometimes requires a hierarchy of its own and the use of script-writing.
This provides some of the elements of how to implement an exposure strategy. Following these rules provides you with a much better chance of successful results (Weg, 2012).
Psychologist Allen Weg has some great tips for practicing ERP for OCD on his You Tube channel:
The International OCD Foundation offers many resources, including sponsorship of an annual conference that includes not only clinicians but also people with OCD and their loved ones:
Weg, A. (2012). OCD checking and washing. Psychology Today. Retrieved from https://www.psychologytoday.com/us/blog/living-ocd/201203/ocd-checking-and-washing
Weg, A. (2011). The many flavors of OCD. Psychology Today. Retrieved from https://www.psychologytoday.com/us/blog/living-ocd/201107/the-many-flavors-ocd