How to Overcome Obsessive Compulsive Disorder (OCD) Using Exposure and Response Prevention and Cognitive Behavioral Therapy: Part One

What is Obsessive Compulsive Disorder (OCD)?

obsessive-compulsive disorder

Check? Check? Check?

OCD is a chronic psychological illness where a person has disturbing and recurring thoughts (obsessions) and compulsive behaviors that they repeat over and over.

OCD is at its core an anxiety disorder. The obsessive thoughts trigger intense anxiety, which the person attempts to ameliorate or reduce by either having compulsive behaviors or compulsive thoughts.

Typical obsessions that people have include:

  • thoughts about harming other people or being aggressive towards other people,
  • inappropriate sexual thoughts and feelings,
  • fear of germs or other types of contamination such as chemical contamination,
  • thoughts about symmetry and order,
  • taboo thoughts about religion or other “hot” issues.

Some typical examples of compulsive behaviors include:

  • Checking behaviors where the person repeatedly checks to see if the stove is turned off or a door is locked
  • Excessive cleaning, hand washing or showering
  • Counting behaviors
  • Arranging things in a particular and precise way
  • I’ve also written about hoarding, which is another type of compulsive behavior.

Some compulsive behaviors are actually thoughts, such as saying a particular prayer to yourself over and over.

There’s an excellent article on OCD at the National Institutes of Mental Health page.

A common type of OCD that I treat in my practice is germ phobia. The typical obsessive thought in these cases is that touching something such as the floor will transfer dangerous germs onto the person’s hands, which will then be transferred either to them or to someone they care about, causing great harm. These people are typically very fearful of public bathrooms and will avoid touching the doorknobs in them. In order to cope with perceived contamination, they will typically wash their hands many times a day, sometimes up to 30 to 50 times. When they cannot wash their hands they will use alcohol gel to sterilize their hands. Often the handwashing is so extreme that the person’s hands will look profoundly chapped and red.

When they feel particularly contaminated they will often take very long showers, washing and re-washing their body very carefully multiple times. These showers can take 30-60 minutes in some cases.

Exposure and Response Prevention Treatment (ERP) for Contamination OCD

OCD that is accompanied by clear rituals such as handwashing is easily and effectively treated using a Cognitive Behavioral Approach that focuses on something called Exposure and Response Prevention (ERP). Let me describe a hypothetical case. (This is a hypothetical case that may include composite aspects of clients I have treated, with all identifiable client information changed.)

Susana came to me because she had developed a very severe case of contamination OCD. Her primary fear was that by touching something that might have germs, she would transfer these germs to her children, husband, or even to strangers, and that they would sicken and die. As a result of these fears, she would wash her hands more than 50 times a day, and take showers that lasted more than an hour during which she would scrub up and wash down three or four times.

She also had developed almost complete avoidances of many situations. Public restrooms terrified her, so she could not leave the home for long periods of time. She was afraid of contaminating her car, which then might contaminate people she loved, so she avoided driving. Work was out of the question since she was spending hours a day on OCD rituals.

The first step was to thoroughly evaluate her OCD. I gave her multiple questionnaires that evaluated the frequency of obsessive thoughts, compulsive behaviors, and avoidant behaviors. The same questionnaires also evaluated the level of anxiety and distress caused by both the obsessions and the compulsions. This gave us a good baseline set of numbers that described the state of her OCD. As part of the same evaluation, I obtained detailed information about all of the things that she was avoiding doing.

The next step was to do some Cognitive Behavioral Therapy (CBT) on her belief systems about germs and contamination. This consisted primarily of a set of conversations where I asked open-ended Socratic-style questions about her beliefs. She showed a variety of common OCD distorted thoughts and beliefs.

Common Thought Distortions in Contamination OCD

  • All germs are lethal and deadly: This distortion is basically the belief that every microorganism causes serious or fatal diseases. It’s actually not true. We are surrounded by bacteria, and most of them are harmless or even beneficial. The most common kind of harmful germs or viruses are the common cold and the flu. Neither these illnesses are particularly dangerous although they are unpleasant. More dangerous germs such as HIV or tuberculosis are extremely rare in developed nations, and the virus that causes HIV is extremely fragile and cannot survive for more than a couple of minutes on most surfaces.
  • Germs live forever on any surface: This is the belief that once a germ attaches itself to a surface it will stay there forever and be capable of infecting you. In reality, most surfaces are fairly inhospitable for bacteria and viruses, and the microorganisms become inactivated fairly quickly, usually within minutes or at most an hour.
  • Things transfer at 100% potency: The law of transfer says that with each transfer the potency of what is being transferred becomes less and less. So if you touch something that has germs on it, your hand will have some germs transfer. If you then touch something, such as a computer keyboard, fewer germs will transfer. Then when someone else touches the keyboard, even fewer germs will transfer to them. The more transfers the less is transferred.
  • Humans have no immune system: This is the belief that every germ or virus that one contacts will cause illness. Humans actually have a very robust immune system. Every day our immune system kills off a variety of germs and viruses we get exposed to. Unless we are exposed to many germs or viruses, our immune system usually does a good job of resisting illness.

The Treatment: Using Exposure and Response Prevention

We did some experiments to test her beliefs. One experiment I like to do is the chalk dust experiment. I have the patient touch some chalk dust, and then they touch my hand, and then I touch my keyboard of my computer, and then I have them touch the keyboard with a clean hand. Thus they graphically see that each transfer moves less and less chalk dust to the next item.

We spent a few sessions discussing and correcting the misconceptions about germs and illness. This began the process of getting ready to start the essential part of the treatment, Exposure and Response Prevention. (ERP)

To prepare for ERP we first made a laddered list of things that would be scary for her. The list went from fairly easy tasks which were a little scary, to tasks that would be terrifying. We rated the anxiety on a 0-10 scale.

I asked her to pick a task that would be somewhat challenging but not terrifying to start with. She picked a task with moderate fear attached to it, touching the floor of my office (which is a carpeted floor.) I also told her that anything that I would ask her to do I would also do with her.

I had her rub both hands on the carpeted floor. Then I asked her to just sit with her anxiety. Initially, her level of anxiety was 10 out of 10. I asked her to narrate her thoughts. “My hands are covered with dangerous germs,” she said.

Over 15 minutes or so her anxiety began to diminish. It went down to about a 7. I noticed that she was holding her hands in the air, so I asked her to put them on her lap. This increased her anxiety briefly, but after a few minutes he anxiety came back down to a 7.

Over another 20 or 30 minutes, her anxiety came down even further. Now it was only a level 4. I asked her to describe her thoughts. “Your carpet probably isn’t really covered with very many germs, and therefore my hands probably don’t have very many germs on them,” she said.

Then I asked her to do something a little bit more challenging – to rub her hands on her face. This made her anxious, but she did it, and after a few minutes of higher anxiety the anxiety subsided again.

By the end of our official face-to-face session, her anxiety level was a 3 out of 10. I asked her if she had any alcohol gel or cleanser in her purse, which she did, and I asked her to leave that in my office. Then I asked her to spend at least another 30 minutes in my waiting room to see if the anxiety level would come down even further, without washing or cleansing her hands. At the next session, she told me that the anxiety level had come down to a level 2, which amazed her given that she had started at 10. I had asked her not to wash her hands for several hours which she did.

At the next session, we tackled another item on her list, the ATM. She was afraid to touch ATMs with her fingers, and either used the back of her knuckles or used alcohol gel after touching the ATM. So we went next door to the local banks ATM, and I had her repeatedly touch the keys with her fingertips. This brought her anxiety level up to about 7, so we kept repeating the task until the anxiety began to subside. Once again I asked her not to wash or use alcohol gel.

A few sessions later after using exposure and response prevention on a variety of other issues, we tackled the top of her list – the public restroom! For many contamination OCD patients, this is the ultimate challenge. We went next door to the building’s restroom, where I put a sign on the door, Closed for Maintenance. Next, I modeled touching the doorknob, the sink, and she did the same. We went back to my office and once again she sat with her anxiety until it came way down.

Once her anxiety had dropped we went back into the restroom and did a harder task. First I modeled touching the toilet seat, and then she touched it. Not surprisingly this raised her anxiety very high. Once again we went back to my office and she sat with that anxiety. We discussed the nature of what toilet seats are made of, and how long germs could live upon them. Gradually her anxiety diminished to about a level of 5, which was a large drop for her.

Between sessions, I asked her to practice these tasks on her own. I explained that the key was to sit with the anxiety for a long enough time for it to subside naturally without any hand cleaning or sterilization. She practiced on a daily basis and made rapid progress on the items we had done together and some other items that were also on her feared list.

By this point, she had lowered her hand washing from 40 or 50 times a day to only several specific situations. After using the toilet, before preparing food, and after preparing food. She had stopped using alcohol gel completely.

A few months later she began to look for work for the first time in several years, as her OCD was virtually completely resolved. I continued to see her intermittently over the next few years, and her OCD continued not to be a problem, although there were some other non-OCD challenges.

In Part Two of this article, I will discuss the use of medications for the treatment of OCD, Thought OCD, Checking OCD, and Health OCD.

 

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Forgiveness and Happiness Researcher Fred Luskin Says Turn Off Your Smartphone If You Want to be Happy

Earlier this year I had the good fortune to spend several morning hours listening to Stanford professor and researcher Fred Luskin talk about happiness. Dr. Luskin is a psychologist who has done groundbreaking research on forgiveness over many years. He’s the author of many books, and frequently lectures about forgiveness. I often recommend his book Forgive for Good: A Proven Prescription for Health and Happiness to clients suffering from anger and hurt.

But this morning he was discussing happiness. He came into the room with no pretense. His hair was wild and curly, partly dark and partly gray. He was wearing a puffy black down jacket, a T-shirt, running tights, and sneakers. Clearly a man comfortable with himself, and not trying to impress.

He started off by doing something quite outrageous. He asked the audience of 30 people to turn off their cell phones. Not to lower the volume, or turn off the ringers, but to actually shut down their cell phones. This clearly caused some discomfort among the audience. He explained that the reason he wanted people to turn off their cell phones is so that they would truly focus on the present and to listening to him. He cited a statistic that people check email on average 79 times a day. Each time they check their email they get a burst of adrenaline and stress. Clearly this is not conducive to genuine happiness.

He pointed out that you can’t really be happy unless you can sit still and relax. “We are all descended from anxious monkeys,” he said, and clearly most of us do not know how to sit still and relax. “Happiness is the state of ‘enough’ “, he said, “and is not consistent with wanting more.”

He pointed out that wanting what you have equals being happy. And that wanting something else than what you have equals stress.

He talked about the beginnings of his career, when clinical psychology was focused on unhappiness and problems. There was no science of happiness. Now there is a huge area of research and writing on happiness called Positive Psychology.

He shared some simple techniques for enhancing happiness. One simple technique revolved around food. When you’re eating don’t multitask. Give thanks for the food, and really focus on tasting and savoring that food. One technique I have often used is to close my eyes while I savor food, which greatly intensifies the taste.

Another simple practice is whenever you are outside, take a few moments to feel the wind or sun on your skin.

He also talked about phones and how we use them. We are completely addicted to the little bursts of dopamine and adrenaline that we get each time we check our email or we get a text. And rather than be present in most situations, we simply look at our phones. Go to any outdoor cafe and look at people who are sitting alone. Most of them are looking at their phones rather than experiencing the surroundings or interacting with other people. Even sadder, look at people who are with others, either at a cafe, or a restaurant. Much of the time they too are lost in their smartphones.

He discussed how happiness is not correlated with achievement. Nor is it correlated with money once you have an adequate amount to cover basic needs. What happiness seems to be most correlated with is relationships. If you like yourself and connect with other people you will tend to be happy.

He reviewed  the relationship between impatience, anger, frustration, judgment and happiness. He pointed out that whenever we are impatient or in a hurry all of our worst emotions tend to come out. When someone drives slowly in front of us we get annoyed. When someone takes too much time in the checkout line ahead of us, we get angry.

I really liked his discussion of grocery stores. He pointed out what an incredible miracle a modern American grocery store really is. The variety of delicious foods that we can buy for a relatively small amount of money is truly staggering. But instead of appreciating this, we focus on the slow person in the line ahead of us, or the person who has 16 items in the 15 item express line. What a shame!

He pointed out we have a choice of what we focus on, and this choice greatly influences our happiness. We all have a choice to focus on what’s wrong with our lives, or what’s right with our lives. And we have a choice of whether to focus on how other people have treated us poorly, or how other people have treated us well. These choices of focus will determine how we feel.

We also have the choice of focusing on what we already have, or focusing on what we do not have and aspire to have. For instance, let’s imagine that you are currently living in a rental apartment. The apartment is quite nice, although there are things that could be better. The kitchen could be bigger, and the tile in the bathroom could be prettier.

Perhaps you imagine owning a house, and you feel badly about renting an apartment. Rarely do we appreciate what we have. Having a place to live is clearly infinitely better than being homeless. And even a flawed apartment is still home.

All of us need to work on learning to emphasize generosity, awe, and gratitude in our lives if we want to be happy. Generosity means kindness and acceptance in contrast to anger and judgment. Awe is the ability to be astounded by the wonder and beauty in the world. Gratitude is appreciation for all the good things in your own life and in the world.

He cited one interesting study where researchers observed a traffic crosswalk. They found that the more expensive cars were less likely to stop for people in the crosswalks. Thus wealth often correlates with a lack of generosity and a higher level of hostility. Other data shows that there is very little correlation between wealth and charitable giving, with much of the charitable giving in the USA coming from those of modest means.

He also talked about secular changes in our society. He quoted a statistic that empathy is down 40% since the 1970’s. At the same time narcissism has increased by roughly 40%. This has a huge negative impact on relationships.

I was impressed by this simple but profound message of Dr. Luskin’s talk. Slow down, smell the roses, turn off your phone, focus on relationships, appreciate what you have, and become happier.

It’s a simple message, but hard to actually do.

I’m off to go for a hike in the hills, without my phone!

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Good News! You May Be Getting More Sleep Than You Think, Especially If You Suffer Insomnia!

The Wall Street Journal today had a very interesting article about how people with insomnia tend to greatly underestimate how much sleep they get and overestimate how long it takes them to fall asleep. They also overestimate how often they wake up at night.

Roughly 30% of adults have some insomnia each year. About 10% of people have chronic insomnia which means that you have trouble sleeping three times a week or more. According to the Journal article, 42% of insomniacs who actually slept the normal amount (6 hours or more) underestimated how much they slept by more than an hour. I looked up the research article which was published in Psychosomatic Medicine. According to this research, insomniacs who slept six hours or more typically showed a profile of high depression and anxiety and low coping skills according to psychological testing.

What’s also interesting is that even though insomniacs may be sleeping six or more hours a night, there does appear to be some real differences in their brainwave activity compared to good sleepers. Even though they are asleep, their brains are more active, which may account for why they perceive their sleep to be less than it really is.

Another interesting factoid was that normal people tend to overestimate how much sleep they get. Most people when asked how much sleep they get will answer between seven and eight hours, but they are actually getting six hours. That’s why people tend to be so sleep deprived. For most people six hours is not enough sleep to feel really good.

So what’s the answer to this sleep estimating dilemma? It turns out there is a very simple answer. The two gold standards for measuring sleep are brainwave measurements and activity measurements. While brainwave measurements are difficult to come by in the home, activity measurements are very easy and inexpensive to obtain. Many of the current fitness tracker’s have a sleep tracking function. For instance, according to my Xiaomi Mi Band, which cost me the grand sum of $15, last night I was in bed for seven hours and 58 minutes, and got three hours 20 minutes of deep sleep and four hours and 38 minutes of light sleep. I was awake for one minute. (Yes, I know, please don’t hate me all you insomniacs!)

For insomniacs who worry about how much sleep they are getting, I recommend buying a fitness tracker and wearing it every night. The best ones automatically track sleep without having the requirement that you push a button to activate sleep mode. This is pretty important as most people forget to press the button. I have been pretty happy with my Xiaomi Mi Band, which you can buy directly from the company  but I’m sure there are other brands of fitness trackers which offer similar features.

Also, as I’ve written about previously here and here, cognitive behavioral therapy for insomnia (CBT-I) may also improve the quality of sleep as well as the quantity. Some studies show that CBT-I improves people’s ability to accurately estimate their sleep time, and it also may calm  the over-activity of the brain that occurs when insomniacs sleep.

So here’s the executive summary for all of you sleep-deprived folks:

1. If you are an insomniac who is anxious and depressed, then you are probably getting more sleep than you think. Buy a fitness tracker with a good sleep tracking function, and you will see how much sleep you are actually getting.

2. If you want to improve the quality of your sleep, either practice meditation or see a CBT psychologist for CBT-I, as both of these interventions seem to lower the activity of the brain during sleep, which will improve your perception of your own sleep.

3. If you consistently feel anxious or depressed, consider getting some cognitive behavioral therapy for these problems, as they may contribute to sleep difficulties.

I’m off to bed now and hope I don’t have insomnia now that I’ve written about it!

 

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.