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What
is Obsessive Compulsive Disorder?
Obsessive Compulsive Disorder (often referred to simply as OCD) is
a broad brush label which covers a very wide range of
difficulties. Though symptoms can vary hugely, the condition is
marked by either obsessive and/or compulsive thoughts and/or
behaviours which usually create an enormous amount of anxiety for
the sufferer. Often a compulsive thought or behaviour will be
seemingly irrational, but the sufferer will nonetheless be
compelled to complete the behaviour by a strong feeling of
anxiety. The anxiety will usually diminish upon completion of the
behaviour, thus offering, on the face of it, an antidote to
anxiety. These behaviours, once begun however, often become
strongly engrained as patterns of daily rituals which must be
completed in order that the sufferer can go through the day with a
manageable level of anxiety. Being denied the opportunity to
complete the anxiety reducing ritual, the sufferer will often
become very anxious indeed. Sufferers will be only too aware that
the thoughts or compulsions themselves are irrational but that
does not diminish the need to ritualise. It’s easy to see then
how this condition can severely limit a persons’ experience of
life.
Do
I have OCD?
It’s worth pointing out that obsession and compulsion are basic
components of every mind. Most of us have a healthy level of
obsession. We know that it might be a good idea when we’re out
to check every hour or so that we still have our wallet or handbag
with us. Most of us will check that the door is locked when
leaving the house. Often, in absent-mindedness we’ll return just
to make sure! Most people know the feeling of being half way down
the motorway and thinking “You know I don’t remember….DID I
turn the gas off?!” The compulsion to return to check can be
overwhelming for some people, but still it can be considered
“normal”, because these are real concerns which require
mindfulness. Most people will also recognise that the mind has a
natural tendency to repeatedly return to uncomfortable or
embarrassing moments or indeed to moments where there has been
conflict. There is an effort by the mind to balance difficult
feelings or thoughts by re-running them in an attempt to make it
right this time. Irrational as it is, we all know that feeling of
watching a movie and wondering (just for a moment) whether,
despite the fact that last time we saw the movie the hero’s
girlfriend met an unfortunate end that “this time” she will
make it through? Like it or not, there’s not a person on the
planet who hasn’t had the disconcerting experience of having at
some time or another a depraved or evil thought despite having no
actual affinity with that thought or idea. Research has shown that
difficult or destructive thoughts are experienced by approximately
80% of the population (this crosses cultures too), and it is now
widely recognised that although we perhaps don’t understand
quite WHY this should be so, we do know that it is a common
experience and DOES NOT indicate a personality disorder. It simply
seems to be part of having a brain! We think “Where did THAT
come from?!” “That’s not what I feel!” Most of us will
easily be able to allow those thoughts to simply come and go, rare
as they are, and think no more of them. We recognize that they are
not indicative of who we are. Even avoiding walking under ladders
is an irrational compulsion. So, everybody can relate to the
symptoms of OCD. Everybody has experienced some of the symptoms,
albeit in a manageable and diluted form. With OCD however, it can
become very difficult to separate oneself from those thoughts, and
with over-identification and increased anxiety, those thoughts can
become overwhelmingly dominant. The problems begin then, when
these natural inclinations seemingly take on a life of their own,
and escape the control of the intellect.
Typically speaking a person will be diagnosed as being an OCD
sufferer when the obsessions and compulsions create real distress,
consume over an hour a day, and/or significantly interfere with a
persons’ ability to function normally in society; that is to say
at work, at home, and socially. Recent figures show that
approximately 2-3% of the UK
population has OCD. We know that in fact a very high proportion of
people will suffer from mild compulsions and obsessions. These
would not necessarily be diagnosed as OCD, and often will remain
private, but they can be troubling nonetheless.
What are the symptoms?
Symptoms are as varied as one can imagine. We can become obsessive
or compulsive about literally anything. Common obsessions are
repetitive, involuntary, unwanted, often distressing thoughts,
images or impulses which include, but are not limited to: -
·
Harming or hating – others, oneself, or loved ones.
·
Fears about contamination - germs, dirt, virus’s etc. Worry
about “infecting” others.
·
Hypochondria - Excessive worry about illness, and/or death of self
or others.
·
Jealousy, envy, or becoming inappropriately overly concerned with
another’s life.
·
Violent or intrusive sexual thoughts.
·
Thoughts of impending doom or disaster.
·
Persistent, repetitive need to check potentially harmful elements
for safety.
·
Irrational concern with form, number, or measure.
·
Extreme perfectionism/preciseness.
·
Upsetting thoughts of blasphemy.
·
Appearance – inappropriate attention to detail.
Compulsions
are just as varied as obsessions and often complete the cycle of
anxiety reduction. So a person who has obsessive thoughts about
germs and contamination may feel a strong compulsion to clean and
disinfect. Compulsions can also be driven by obsessional thoughts
of keeping order which can manifest in odd behaviours seemingly
unrelated to anything rationally apprehended. Compulsions may
include, but are not limited to: -
·
Repeated checking gas is off, windows are sealed, plugs unplugged,
doors locked etc.
·
Continually showering or washing (hands usually).
·
Touching objects to make sure they are there.
·
Arranging, and ordering. Ornaments or collections. Lists and lists
of lists.
·
Counting. (Teeth, tiles, flowers, wallpaper squares, anything
countable).
·
Cleaning and disinfecting (both for self and others).
·
Self harming
·
Hoarding useless objects.
·
Hair pulling and eating (trichotillomania). Spot/skin picking.
·
Difficult cyclic routines which must be practiced precisely.
·
Restyling hair/clothes/makeup repeatedly before being able to
leave home.
This is only a sample list of possible obsessions and compulsions.
The list could be almost endless. It’s important to note though
that if you do have an obsession or compulsion listed above it
doesn’t necessarily mean that you have OCD. The distinction and
diagnosis is one of degree, and though OCD is a serious disorder,
it is still a label for an extreme form of what most of us do to
one degree or another anyway. Even if you have been diagnosed as
having OCD, it doesn’t always help to identify too closely with
that “label”. It can be helpful to know that the condition
that you are suffering with is recognised and has a name since it
gives you a sense of normalisation, but in the long term it’s
sometimes unhelpful to associate too closely with being a
“victim” or a “sufferer”. Ultimately, you need to be able
to separate yourself from the symptom which sends the message that
you have the power to do something about it. Much of an OCD
sufferer’s distress will be created by the mistaken belief that
the thoughts or compulsions are in some way indicative of a
twisted core identity. This must be challenged. Indeed, this is
the first rule of treatment with OCD. You are not your OCD.
Remember, at worst, your OCD is only a percentage of your life.
How do we “get” OCD?
We may less “get” OCD, than always have had it. The truth is,
the exact mechanisms of OCD are still not completely understood,
though we do see different patterns of activity in the brain in
OCD sufferers which show the "housekeeping" areas of the
brain are overheated and over active. It is believed that the part
of the brain which promotes the feeling of something not being
right (which of course is useful when firing appropriately)
actually gets stuck in the open position making it very difficult
to shake the feeling that something is wrong. The anxiety creates
an extension of normal patterns of worry, concern, or interest,
into an unhealthy level of obsession which results in compulsive
behaviours carried out in an effort to create order, solution, and
reduce anxiety. It seems that certain personality types may be
more pre-disposed to OCD, and we know that in terms of recovery
it’s not necessarily a case of being “cured” of OCD. It’s
more realistic to think of the condition being in remission. To
put it another way, if you’re a person who tends to be obsessive
and/or compulsive, or are pre-disposed genetically to OCD then
that may well be part of your core personality. This is no cause
to lament. When properly channeled, these tendencies can be
incredibly useful and productive. The correct measure of
compulsion to clean the house, or drive carefully is useful and
healthy! Equally of course, some of the greatest pioneering
contributions to our World have been made by people with obsessive
personalities. Many people manage with therapy (which can be self
directed of course) to reduce their symptoms by as much as 90%
(some claim even higher success than this!) and often people who
take control of their OCD lead rich lives.
So,
often it’s much more about creating manageable patterns than it
is about being “cured”, and long term condition management is
usually much easier following recovery since one learns along the
way what factors contributed to both the creation and the solution
of the difficulty. Thus, a measure of control is attained which
was not available first time around. Perhaps a more useful
question to ask then is “What do we know about OCD?” and then
“What is the way out?”
Whilst we know that there is an involuntary cognitive (thinking
style) distortion involved, OCD is usually classified as an
anxiety disorder (as opposed to cognitive) since most sufferers
(80%) will already be aware that their thoughts and compulsions
are irrational. Cognitive therapies are ordinarily concerned with
recognition and correction of unreasonable and irrational
thoughts. Though this is certainly helpful in tackling OCD it can
be of limited value when used alone, since the sufferer is already
usually only too aware of the unreasonable/irrational nature of
their thoughts. The disorder begins at the emotional level.
Therefore, as well as the longer term cognitive and behavioural
adjustments required for recovery, successful treatment should
include a practical method for reducing anxiety. When emotional
arousal (anxiety) is reduced, then it becomes much easier to
correct thoughts and challenge behaviours. I will qualify this
position.
The
science of anxiety and OCD.
Studies
show that serotonin levels in the brain are erratic and unbalanced
in OCD sufferers. This is also found to be the case where people
are suffering with depression and anxiety so the parallels are
clear. It is unsurprising therefore to note that some common
anti-depressant medications (Anafranil, Prozac, Luvox, Paxil, and
Zoloft) are shown to be helpful in treating OCD. We know however
in the treatment of depression that anti depressant medication
used alone is of limited effectiveness, because there are factors
which are shown to create depression which are not purely
chemical. It is arguable that the imbalance of brain chemistry we
find in depression is as much a result of depressive thinking as
it is the cause. If the cause of depression is in part a negative
thinking style, then we will remain much more prone to depression
if this is not addressed…with or without the aid of
pharmacological intervention. OCD may well be the result of a
combination of factors…biological, neurological, cognitive,
behavioural, emotional and chemical. The truth is though it’s
difficult to say which of these is the cause and which is the
effect, though it appears at least at first to be primarily a
neurological condition. It is helpful to think of it in these
terms when setting out to overcome it since this gives substance
to the assertion that the difficult thoughts or feelings are not
you! They are a misfiring within the brain. It is most probably a
combination of factors. What we do know though is that behavioural
therapy used in conjunction with medication and an anxiety
reduction plan covers all the bases and will usually create an
effective combination. Medication, obviously, should be discussed
with your GP.
Interestingly, brain scans in OCD sufferers have also shown that
the amygdala, which is an almond sized part of the brain near the
brain stem, becomes highly active when compulsive behaviour in OCD
sufferers is challenged. The amygdala is a primitive,
instinctively driven part of the brain which is responsible for
triggering the fight or flight mechanism when we are threatened -
the fear response. It is the amygdala which creates problems for
us when it fires inappropriately, such as it has been shown to do
in people who have irrational fears, phobias, or panic attacks. We
can see that if this part of the mind is being activated as a
response to having these behaviours challenged, then in a very
real sense we are talking about an anxiety disorder. The thought
of not carrying out the behaviour creates a fear response, and we
know that when the amygdala is triggered to deliver a fear
response, the resultant feelings can be experienced as being
overwhelming. This is because this is the part of the mind which
deals with survival, and thus it has the ability to override the
intellect, as it would do in any situation where we are faced with
danger. When faced with danger we respond instinctively, not
intellectually. This explains why there is such a strong
instinctive drive to carry out these behaviours despite their
irrationality. There are many explanations as to why the mind
becomes obsessive, some of which we had discussed in our earlier
example but one thing that we can all recognise for certain is
that we are much more likely to become obsessive when we are
highly emotionally aroused. In my work here as a therapist, I see
this to be the case absolutely. When we are highly stressed it
becomes much more difficult to enjoy a restful mind filled with
calm thoughts. The mind instead becomes emotionally aroused and
overactive (obsessed). When we are highly stressed we also become
hyper-vigilant which means that we start to notice and become
alarmed by things which might not bother us ordinarily, adding to
the already difficult mix. So, we can in this loop, become overly
concerned with cleanliness, order and control. We also find when
the emotional mind is overly aroused in this way, it can become
all but impossible to take intellectual control and instead we
begin to become almost entirely instinctively and emotionally
focused. We know that the emotional mind can be very irrational
(we have all been unreasonable or irrational in times of high
emotional arousal), and this is a significant factor in
understanding why compulsions can be so irrational. Simply put,
the irrational emotional mind becomes overdriven and commands a
much greater deal of control than is usual or healthy. This is a
result of too much emotional arousal (stress, anxiety), coupled
and compounded by the resultant belief of powerlessness, which
perpetuates the cycle of poor self-esteem, shame, guilt, feelings
of being out of control, exhaustion, fear etc. With all this going
on, it’s hardly surprising that depression and anxiety often
exist alongside OCD.
An
Example
Obsessional
behaviour is a fear response. If we feel threatened by something,
then the mind moves into a hyper-vigilant mode and
invariably begins to "notice" or "pick up" on
thought patterns which relate to that threat in some way. Whilst
acknowledging that OCD does have a neurological factor, let's just
have a look at how obsessive behaviours could begin in anyone:-
Suppose
a wife loses her husband. At any given time, any one of us could
have a reasonable level of concern about being burgled, but that
thought process will sit comfortably at the back of the mind, in
it's proper perspective. In our example however, the lady who has
lost her husband becomes extremely anxious as a result of that
loss. In an effort to bring order and control to a situation which
has left her feeling out of control and unsafe she now starts to
worry about security in a big way. She has an overwhelming need to
eliminate any further threat or danger and thereby undertakes to
"check" that the windows are secure, that the doors are
locked, plugs are unplugged, that hands are clean (germ free) etc.
"Checking" increases the strength of the response,
because it sends the message (by behaviour) that we agree with the
assumption that there is inherent danger in the environment. This
increases the need of course for more vigilance. And then another
thought crosses her mind. Having lost her husband she begins to be
troubled by the thought that she might not be able to cope if
anything were to happen to her daughter. What if...? What if.....?
She begins to imagine scenarios. Terrible scenarios; perhaps
scenarios where she herself might have some part in her daughters
demise, and having such irrational ideas begins to make her wonder
if she can even trust herself? Day by day the imaginings become
more and more detailed, more and more vivid. Well, central to the
workings of hypnotherapy is the recognition that the imagination
is an extremely powerful tool. It can be used positively to create
foresight and innovation which can inspire us to positive action
or it can be used negatively to create worry and anxiety which can
paralyse us with fear. The instinctive mind responds to what we
imagine, as well as what really is. The now hyper-vigilant
instinctive mind, seeing these dreadful happenings (in the
imagination) day in, day out, assumes that this lady really must
be living in a terrible place filled with danger, and steps up the
level of vigilance and the resultant need for security to an even
higher degree. Now the mind, believing that the World is such a
hostile environment filled with dangers seen and unseen, switches
to "Red Alert"....and begins to "notice" even
more things which are a cause for concern, silly things,
irrational things. Some of these things it may not be possible to
actually control in any way. So in the presence of such great
disorder, such a great loss of control, then perhaps there is some
other way to create order? The lady now finds herself compelled to
make sure that the ornaments on the mantelpiece are placed
absolutely symmetrically and millimeter perfect. But there is
still no rest and our lady soon finds that to enjoy any semblance
of peace she needs to know that her daughter is okay and starts to
phone her every hour to make sure. The daughter, seeing her
mothers obvious distress agrees that it's okay for Mum to phone
every hour but clearly this makes the daughter very anxious too.
Occasionally her exasperation spills out into the conversation.
Mum feels dreadful about worrying her daughter like this and
begins to become frustrated with herself ....starts to hate
herself even .....and then the depression and hopelessness sets in
.....and now she worries about her relationship with her daughter.
The very thing she most feared, losing her daughter, is now in
danger of happening it seems. So now she's really feeling like
she's losing control, so more anxiety, more attempts by the mind
to "fix" it......and so on it goes......exhausting
reading isn't it?! We can see how easily the mind can get itself
into a bit of a twist. But the important thing to recognise is
that the condition BEGINS at the emotional level. The emotional
arousal created by any big life event or indeed by anxiety
generally can be sufficient to set this negative process in
motion. Once unleashed of course the anxiety is self perpetuating
and needs no help to sustain itself. So, by this example, one can
see what must happen in order to tackle OCD. Anxiety must be
reduced, relationships improved, control and reason must be
returned, and a new perspective must be introduced. If you read
back through this example carefully, you will also be able to see
how the main contributing factor to the creation of this
difficulty (outside of the life event) was an overload of negative
introspection. In other words, allowing the mind to have free
reign as far as fantasies of negative happenings were concerned.
But then the OCD sufferer didn't know at the time what the
consequences of that introspection might be. Understanding is
everything.
Treatment
The good news is that OCD can be successfully treated. Treatment
consists of two components. If you have followed the logic so far,
you will see that the first thing that we have to achieve is to
reduce that overall emotional arousal (anxiety). You will find
more details on how we go about doing this on this website. Essentially, we do not directly
challenge the rituals or thoughts from day one of treatment. We
know that initially this will be likely to simply create more
anxiety. Instead, we take some time to begin to help you to relax
again generally. When obsessive thoughts or compulsions are
running riot, we know that it is difficult at first to have any
measure of intellectual control. We can make a difference however
by concentrating on relaxation generally (reducing emotional
arousal) and by strengthening and improving those areas of a
persons life where there IS control. As with all of this work, the
importance of good mental hygiene is explained, so it becomes
possible to identify areas of thinking which create and sustain
excess anxiety. This will include looking at what you are and are
not responsible for, challenging negative assumptions, assessing
expectations, self acceptance, the okay-ness of making mistakes,
improving relationships etc. Alongside this, we also address any
other concerns, or areas of life which are out of balance, or
where needs are not being properly met. Successfully implementing
these measures goes a long way to returning a sense of comfort and
control and this is in itself anxiety reduction. It translates
back to the subconscious mind in a number of positive ways. It
creates a space of "safety" which is necessary to reduce
emotional arousal. It also reminds us that we DO have a measure of
control, and that things are not perhaps as bleak as they seemed.
Indeed, even simply learning to relax and decrease emotional
arousal generally will usually bring about a significant reduction
in the symptoms of OCD. This is stage one of treatment, which
continues on alongside stage two when that is begun. Stage two of
treatment can begin when we have achieved the objectives outlined
above (usually three to five sessions in). Now, we know that the
idea of challenging behaviours will seem at first an alarming
prospect to a sufferer. As I have already explained, it will often
trigger a literal (and sometimes extreme) fear response within the
amygdala. Keep in mind however, that since we will have already
worked to reduce emotional arousal and anxiety generally, then we
find that the level of hyper-vigilance reduces too. It then
becomes much more possible to begin to challenge the compulsions
and behaviours successfully. The amygdala itself becomes less
active and less sensitive when our anxiety levels generally are
lowered; the message being that the environment at large is a
safe/r place to be, which of course means that there is less need
for the extreme level of protection (hyper-vigilance) the amygdala
has been providing. We also have another tool at our disposal.
Modern treatment allows us to de-traumatise the amygdala in a
single session. This is the same process we use to treat phobias
and can in some cases be very helpful in treating OCD. By
de-arousing the amygdala with regards to those behaviours which
are over-stimulating a response, we can significantly aid recovery
by reducing the automatic fear response. We know that the brain is
very capable of re-patterning over time so there is every reason
to expect that as we continue to create new patterns then those
new patterns can become dominant in the field of awareness and
ultimately, second nature. So stage two then involves
actively challenging those thoughts, compulsions, and behaviours;
beginning gently of course. So we challenge only those behaviours
which are the least anxiety provoking at first, and then build on
that gently over time. Once there is a sense of confidence that
the behaviours can be successfully and comfortably challenged,
then like everything else in life, we can go on to build greater
and greater success on the foundations of those first early steps.
Alongside this, you can see that each success means a reduction in
that thought or behaviour-creating anxiety, and therefore a
further decrease in emotional arousal. We continue then in that
positive spiral out and away from the OCD and back towards
intellectual control…easier patterns, calmer emotions, and a
clearer mind.
In
terms of the treatments I offer, dealing with OCD is invariably a
longer term treatment. Recovery is not an overnight process as any
sufferer will know, but do remember that solution focused therapy
is “brief” therapy. So when I say longer term, I mean that we
might spend ten sessions working together (more if required, but
not indefinitely) as opposed to the three to six or so which other
difficulties might need. It is important to note that in
considering therapy for OCD, there is every chance of improvement,
but one must be willing to consider the possibility of challenging
the condition…that is to say, recognising that at some point,
one will need to “leave the house having checked the door only
once” (or not “insert behaviour here”). I do understand that
initially this may seem frightening, but in the longer term it
should seem less so as you discover that you can successfully
challenge those behaviours, and this is the method by which
success is achieved. I mention this because, here, with OCD, it is
very much a team effort and it’s never as simple as having your
OCD simply “hypnotised away”…although indirectly that is
exactly what we do by reducing your emotional arousal and helping
you to access the tools you need to deal with the condition. The
real treatment with OCD is self directed behavioural therapy. In
other words, you have to consistently challenge your compulsive
behaviours. Continually challenging those behaviours is what
disempowers OCD over time. Dr Jeffrey Schwartz's four step process
of re-labeling, re-attributing, re-focusing, and re-valuing is
generally recognised as THE model for self directed therapy and
has been shown conclusively to yield extremely good results. His
research shows that this continual behavioural adjustment actually
normalises the patterns of activity in the brain, so one can think
of the results as being quite literal. It is possible to actually
change the way your brain works by doing things differently! We
therefore use his model as the central model for behaviour
modification. Remember also, that as with anything, we don't
change "habits" of a lifetime overnight. Continued
repetition of new patterns is what creates this change in the
brain. If you’re reading this and you’re a sufferer, you will
already know that recovery involves meeting those fears head on
and nobody can actually do that for you, but we can certainly help
to make doing that possible! It is also important to note that
100% recovery does not occur in every case, but almost everyone
could expect to see a marked improvement through taking the right
action. As already stated, with OCD it’s often a case of
creating a comfortable reduction in symptoms and patterns.
Sometimes, perhaps for reasons beyond our knowledge, some people
take longer to recover completely than others. Simply put,
everyone is different, but that is no reason to be doubtful. Do
know that many sufferers recover to go on to lead successful happy
productive lives. With treatment, there is every reason to expect
a high degree of success, and almost without exception we will see
a significant reduction in symptoms with the right approach. The
emphasis as always is on providing understanding, so I aim to
provide you with the support, the space, and as many tools as
possible to ensure that you have all the leverage you need to
achieve success. This includes helping you to discover who you
when you are not your OCD. Generally speaking, I am in the
business of "brief therapy". That is to say that most
difficulties are resolved to satisfaction well within ten
sessions. With OCD we can make an enormous difference within such
a timeframe, but it has been my experience that overcoming OCD is
a longer term process and often my clients may decide that they
would like to stay connected with me on an ongoing basis. I just
wish to make clear that stopping short of creating any
"dependency", this is just fine. No one says "Your
ten sessions are up.....off you go!" We work for as long as
you wish, but it is YOUR decision. I NEVER create dependency in
people. I aim to empower you so you can go live your life with all
the joy and zest you can experience!
The
information provided in this article is primarily concerned with
OCD but the same rationale does of course apply also to lower
levels of obsession and compulsion. We know that there are three
main areas of obsession -Jealousy, Hypochondria, and Fear of
Death. These are very common concerns, and although perhaps not as
debilitating as OCD can still be very troubling nonetheless. These
concerns usually respond very readily to anxiety reduction in just
the same way that OCD will and are therefore very suitable for
treatment with hypnotherapy. I am a trained and certified OCD and
Anxiety Disorders specialist.
If
you would like to book a free initial consultation to discuss your
difficulty with a view
to beginning treatment, then please contact
me.
Please do check back
periodically for new information. These articles will be replaced over
time with new articles and info.
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