Pets & OCD: Contamination

Obsessions focusing on pets and animals incorporate all the common themes: contamination, checking, harm, scrupulosity, and sex. In this 3-part blog series, I discuss some of the common ways OCD obsessions may target our lovable, snuggable friends. This article, Part 2, will focus on contamination obsession associated with pets and animals. Part 1 covered harm and violent obsessions related to pets. Part 3 will address sexual obsessions and scrupulosity, as they pertain to pets and animals. Most everybody loves that shower fresh feeling, right? Not only does it feel good, but it’s probably good for us too. Throughout history, cleanliness and good hygiene practices have been instrumental to reducing our vulnerability to germs, disease, and illness. For survival’s sake, to a certain extent, we’re probably biologically-programmed to prefer clean, hygienic environments, over dirty, disgusting ones. Yet, at the same time, our human weakness for all things cute and cuddly leads many of us to choose to co-habitate with wild — or rather, domesticated — animals. This choice brings with it all sorts of opportunities for OCD to stir up contamination worries. Dogs and cats walk around barefoot outside or in litter boxes, and they tend not to wash their paws or bottoms very often (and when they do, it’s only with our assistance). Moreover, dogs have a predilection for both sniffing other dogs’ rear ends and licking themselves in inappropriate places… Naturally, this licking always tends to happen right before they decide to run up to us and lick us on the face. YUCK! So yes, animals can be gross sometimes. But fortunately, most of OCD’s error messages about how dirty, disgusting, dangerous, and unacceptable this is, tend to be overblown. OCD contamination obsessions about pets and animals come in a couple different varieties. Today, we’ll focus on identifying obsessions related to the fear of contaminating your pet, as well as the fear of being contaminated by your pet. Pet Obsessions – Fear of Contaminating Your Pet These pet obsessions involve accidentally contaminating your pet or making it sick. What if I make my pet sick by accidentally feeding it food contaminated with household chemicals or cleaning products? What if the air freshener I spray gets in my cat’s lungs and makes him sick? What if I accidentally feed my dog tainted or spoiled food? What if bugs accidentally got into my kitten’s food? What if I accidentally spread...
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OCD About Pets and Animals: Harm

Obsessions focusing on pets and animals incorporate all the common themes: contamination, checking, harm, scrupulosity, and sex. In this 3-part blog series, I discuss some of the common ways obsessions may target our lovable, snuggable friends. This article, Part 1, will focus on harm obsessions; Part 2 will cover contamination obsessions; and Part 3 will address sexual obsessions and scrupulosity, as they pertain to pets and animals. Pets. You gotta love ‘em. They’re so cute. They’re so cuddly. They always get excited when they see you. So why does OCD hate them so much anyway? Probably because we love them. Just as OCD tends to torment parents who love their children, OCD also loves to torment pet owners who love their pets. Get ready to brace yourself for all sorts of violent and horrific thoughts about pets and animals. It doesn’t matter what type of pet you have. Dogs, cats, birds, ferrets, bunnies, snakes, flying squirrels, chinchillas, mice, rats, guinea pigs, gerbils, potbellied pigs, fish, horses, cows, chickens, frogs, turtles, lizards, YOU NAME IT! The list goes on and on. Obsessions about pets and other animals can occur across all species. Let’s begin by identifying some examples of pet- and animal-focused OCD harm obsessions: OCD and Pets – Fear of Accidental Harm These OCD violent obsessions often focus on preventing possible harm to pets or other animals. Worries include the fear of causing harm through negligence or irresponsibility. Here are some examples… Fear of not locking a fence/gate properly and having your dog escape and be injured or killed. Fear of leaving on an appliance (e.g., a stove, curling iron), starting a fire, and burning down your house…thereby killing your pet. Fear of forgetting your cat or dog’s medication and causing some type of resultant harm. Fear of accidentally hitting your dog with your car. Fear of accidentally trapping your puppy or kitten in the oven. Fear of unintentionally putting your mouse in the microwave. Fear of inadvertently trapping your dog or cat in the dishwasher. Fear of your cat or dog getting stuck in the washing machine or dryer. Fear of trapping your dog in a hot car or other vehicle. Fear of not closing the front door properly and having your cat or dog escape and be hurt or killed. Fear that you may accidentally harm your rabbit/puppy/kitten while holding it (i.e., break its neck). Fear that...
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Anger and OCD – Getting Mad…

“I hate having OCD! Why can’t these thoughts just stop?!?! How can I be the person I was before?!?!” Many people with OCD are extremely familiar with the anxiety-related aspects of the disorder. OCD is an anxiety disorder after all, so it’s not terribly surprising that anxiety is often core to its experience. But anxiety is certainly not the only emotion that shows up in OCD. I’ve discussed briefly how some people with OCD have symptoms of guilt, shame, disgust, and depression, and how treatment may sometimes need to be modified when these emotions are primary aspects of the disorder. Today, though, I’d like to comment briefly on anger and OCD, which I don’t think I’ve mentioned explicitly in previous posts. Anger can be a powerful force in many people’s OCD. What’s the relationship between anger and OCD? Actually, the relationship between OCD and anger is complex, in that it’s mediated by obsessions, compulsions, or even reactions to developing the disorder. Anger and OCD: Anger as a Trigger for Obsessions Anger is sometimes entwined with anxiety and contributes directly to some types of Pure-O OCD. For example, anger can be a trigger for some people who have harm OCD (e.g., What if getting mad means that I’m capable of harming my family members?). Individuals with violent OCD obsessions may fear becoming angry, because they may fear that it will lead to them “snapping” or losing control. Anger is also sometimes present for those who have OCD with suicide obsessions. For example, “If I feel that I hate my life or am angry with myself, that might mean that I’ll end my own life.” In this context, anger also signals danger and is linked to fear. OCD and Anger: Examples of Anger Triggering OCD Obsessions I felt really mad at my parents, and then I almost felt like I wanted to hurt them. Does that mean I’m a dangerous person? I was arguing with my mom, and I felt an urge to punch her in the face, and I think I actually wanted to. What does that mean? I felt really mad and frustrated at my children, and I wanted to lash out at them. Does that mean that I could actually physically hurt them? I yelled at my kids, and I KNOW I enjoyed it. How messed up is that? Does that mean I really want to hurt them?...
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ERP Tip of the Day #2

It’s ERP tip time. This series of posts focuses on tips to enhance the effectiveness of your exposure and response prevention (ERP). If you’re interested in more ERP tips, click the following link for all the posts in this series. Exposure and Response Prevention (ERP) Tips for OCD Without further ado, here’s another ERP tip to consider when designing your next exposure. ERP Tip #2 When completing your next exposure, avoid rules that dictate what you’re allowed to think during the exposure. If you try to complete an exposure without having a certain bad thought, chances are that you’re setting yourself up to think that very thought. Instead, design your exposure around having that very same unwanted thought. I love it when people with OCD do exposure, but I don’t love it when they have a long list of impossible preconditions that dictate the form of their OCD exposure. The most glaring example of this is when people dictate the thoughts that they should have during exposure. OCD ERP Tip Don’ts What I don’t like: I’m going to touch that doorknob, but I really hope that it’s not wet or slimy. When it’s wet or slimy, it makes me think that it has blood on it, and that I might really be contracting AIDS. I really don’t want to die, so I’m okay with touching that doorknob, just as long as it’s dry as a bone, so that it doesn’t freak me out. What I don’t like: I’m willing to walk across that mystery spot in the parking lot, just as long as it doesn’t look at all red or brown or sticky or possibly organic in some form or another. If it looks that way, it really freaks me out and then it makes me think that I’m tracking AIDS blood everywhere. What I don’t like: I’m willing to look at pictures of kids, just as long as I don’t have sensations in my groin. When I have those sensations, it really freaks me out and I think there may actually be something wrong with me. What I don’t like: I’m okay with holding my baby, just as long as I don’t think about throwing him down the stairs, snapping his neck, or doing something inappropriate to him. If those violent OCD thoughts show up, I’ll be really freaked out, and I won’t be able to handle it....
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Contamination OCD – Long Shower Exposures

Long shower times? Just a quick announcement… I’m pleased to announce that with our recent office renovations, we now have a spa-like therapeutic shower room that is perfect for individuals with contamination OCD who have excessively long shower times. This room is ideal for those with contamination OCD who wish to work on shower-based response prevention. For individuals with contamination OCD who take really long showers, we are now able to provide office-based interventions for reducing your long shower times. We’ve had great success with reducing our patients long shower times from multiple hours to a mere 10-15 minutes. Reduce Long Shower Times to Short OCD Shower Times We do this first by developing shower-based response prevention guidelines and modeling non-OCD based shower behavior in-session. We essentially use a shower script to help individuals identify normal shower routines (which, to many of our patients’ surprise, DO NOT include hand-washing behaviors between washing each body part). We practice these routines out of the shower so that our patients can get individualized coaching on these routines. These simulated showers are first performed in our therapy rooms with a therapist, but then are performed in virtual reality (VR) in a virtual model of our office-based shower therapy room. Our shower scripts are then digitized and downloaded to our patient smart phones, and we then have our contamination OCD patients practice these routines in self-directed exposures in their own homes (in their own showers, but without running water). Due to this practice, long shower times start give way to shorter shower times. We also have individuals with OCD complete imaginal exposure. Next, we have our contamination OCD patients practice their showers in-office (with running water) in a spa-like shower room. Although our shower is sterilized after each exposure, the very act of using a public shower is, itself, an exposure. To facilitate these shower-based exposures, we use the same digitized audio script that we used in our simulated exposures to guide the shower. Importantly, we’re also available live via specialized audio technology to coach our patients in implementing this protocol. Patients have full privacy in our spa-like shower room, yet they have the benefit of a live therapist coaching them remotely. In the event that a patient deviates from their script and begins taking a long shower, we can pause the script, get them back on track via coaching, and then resume the...
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ERP Tip of the Day #1

Starting today, I am going to start posting random ERP tips as they occur to me, as there are certain roadblocks that many of my OCD patients tend to encounter. If it’s helpful for my patients, maybe it’s helpful for you. If you’re interested in more ERP tips, click the following link for all the posts in this series. Exposure and Response Prevention (ERP) Tips for OCD These posts will probably be a bit shorter unless the concept requires a more thorough discussion. Please feel free to leave comments below, if you need more information. Today’s tip is… ERP Tip #1 Do not label your rituals as ERP. Instead embrace openness, defenselessness, and vulnerability. You might think that you never do this, but it happens more often than you think. Some people that I know will encounter triggers for their OCD in a normal, everyday situation. In the past, they might have avoided this trigger by closing their eyes or walking away. However, now that they’re trying to practice non-avoidance and deal effectively with their OCD, they may force themselves to look directly at their trigger. So far so good, right? No rituals in sight yet, but… BAM! They find themselves staring intently at the trigger as a way to internally check their physical or emotional response to it. I see this happen commonly with sexual obsessions (particularly people with pedophile OCD [POCD] and sexual orientation OCD [sometimes called HOCD]) and violent obsessions, but it can occur for virtually any type of OCD. For example, someone with pedophile OCD may be looking at the trigger while intently monitoring their groinal response to the child they see. If they don’t notice arousal sensations, they pat themselves on the back. They think they’re doing exposure by looking, but they are actually performing a reassurance-based checking ritual. These rituals make you feel good in the moment, but they further link the perception of a trigger with the mental ritual of checking (and consequent reassurance), which ultimately perpetuates the OCD cycle. The better alternative is to look at the trigger, feel whatever you feel, try to resist internal checks…but if you do check, SPOIL THE RITUAL! Remind yourself purposefully that it’s possible you might still be attracted to children. Why would I suggest such a thing? Because OCD is smart. The good feeling that comes from reassurance is transient. If you reassure yourself,...
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Imaginal Exposure vs. In Vivo Exposure for OCD

As I’ve talked about in numerous posts, overcoming OCD involves learning to co-exist with doubt and uncertainty. This idea can be a bit counter-intuitive at first, as many people initially expect OCD treatment to reduce uncertainty. One therapeutic approach that helps with this process is exposure and response prevention (ERP) for OCD. Not surprisingly, ERP consists of two parts: 1) exposure, and 2) response prevention. An exposure is when you do something on purpose to provoke an anxiety spike. By definition, exposures are not accidental; rather, they are pre-planned, deliberate offensive strikes against your OCD. Exposures are designed to help you build up your tolerance to fear-producing situations. Exposures are often completed according to an exposure hierarchy, meaning that people typically complete lower level exposures (i.e., less distressing exposures) before gradually working up to higher level ones. Response prevention refers to the idea that after the exposure, you will allow your anxiety to naturally decrease on its own without artificially forcing it to decrease prematurely through rituals. Response prevention is most effective when one resists ALL rituals, including both behavioral and mental rituals. Behavioral rituals may include things like washing, checking, or rearranging; whereas mental rituals may include self-reassurance, thinking “safe thoughts”, praying, or mental review. Avoidance is also considered a ritual. Exposures come in two forms: in vivo exposure and imaginal exposure (also referred to as “scripting“). In Vivo Exposure for OCD When we think about exposure therapy for OCD, we often think first about in vivo exposure. In vivo ERPs involve directly exposing yourself to feared situations in real-life. For example, a person with contamination OCD might develop a hierarchy of in vivo exposures that involve purposefully touching “dirty things” like doorknobs, light switches, trashcans, animals, or even toilets. The goal of these in vivo exposures is to face the fear directly without ritualizing. This means that after touching these contaminated objects, the person would refrain from washing their hands, using hand sanitizer, getting reassurance, mentally reviewing reasons why it’s okay to not wash, or doing anything else to neutralize the perceived danger of the situation. Likewise, someone with harm OCD might develop a hierarchy based on putting themselves in feared situations. These feared situations should evoke the fear directly or present opportunities for the person to act on the fear. For example, someone who is afraid of stabbing their spouse might expose themselves to situations such...
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Common Misconceptions About Anxiety & OCD Treatment

People new to OCD treatment often walk through the door with more than a few misconceptions. Here are some common ones: Misconception 1: Anxiety is bad. Actually, anxiety is a normal, functional, biologically-based phenomenon that every person is capable of experiencing. The only people who are truly anxiety-free are dead people. The rest of us (the living ones, at least) will find that anxiety will be a part of our lives, at least to some extent. Some anxiety is good and can be helpful. For example, it’s probably good to have some anxiety when you’re studying for a test. This anxiety can help motivate you to prepare sufficiently. Similarly, it’s probably good to have some anxiety about doing dangerous things, such as driving too fast — this anxiety might just save your life. Of course, not all anxiety is good or functional. Some anxiety spikes occur for no good reason and don’t have an upside. These false alarms make us feel bad for no good reason. Panic disorder is the perfect example of this. In panic disorder, your fight-or-flight system gets continually reactivated in situations where it isn’t warranted. Treatment of panic disorder involves learning to disregard the danger messages attached to your panic symptoms. The goal of OCD treatment (or the treatment of any anxiety disorder, for that matter) is not to eliminate anxiety, but rather to recalibrate your anxiety system so that there are fewer false alarms, and anxiety is again serving a useful purpose. When you finish OCD treatment, you’ll still have anxiety. It just won’t be standing in your way like it is now. Misconception 2: Avoidance is an effective solution for anxiety. There is no denying that avoidance is an effective solution for reducing anxiety. However, the anxiety-reducing effects of avoidance are short-lived and come at a great cost. Reliance on avoidance as a coping strategy may reduce your anxiety in the short-term, but it dramatically increases anxiety over the long-term. If avoidance is left unchecked, anxiety often grows to a point where it becomes debilitating and interferes with our functioning. Why does this happen? In essence, avoidance brainwashes us to believe that if we didn’t avoid, the worst would have happened. Let’s examine this in relation to a common contamination OCD thought: “Germs are everywhere. If I don’t touch the dirty doorknob, then I won’t get sick.” Avoidance of the doorknob prevents anxiety...
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OCD Awareness Week 2016

It’s #OCDWEEK! Help raise awareness and understanding about obsessive compulsive disorder (OCD) and related disorders. Welcome to #OCDWEEK 2016, a week organized by IOCDF to help raise awareness about OCD and related conditions! If you visit IOCDF’s website, you’ll find information about local and online programs and events designed to help increase the general public’s understanding of OCD. When I started this blog a few years ago, the internet was awash in misinformation about the nature of OCD. OCD was (more often than not) described in oversimplified terms, and the popular media largely mischaracterized OCD as a disorder defined primarily on the basis of excessive washing or checking behaviors. If you didn’t fit this mold, it was implied that you didn’t have OCD. I was hoping that, through my writing, I might be able to address some of these misconceptions and bring awareness to some aspects of OCD and anxiety treatment that were often overlooked or poorly understood. For each person with contamination OCD or checking OCD, there was another person with Pure-O OCD wondering, “What’s wrong with me? Am I the only one who has these thoughts?” On the surface, these various manifestations of the disorder can seem quite different, but truly, there are unifying concepts and processes that unite these disparate forms of the disorder and transcend obsessional content. One of the marvelous things about attending an OCD support group is that you can learn so much about your own OCD by simply listening to how other people talk about theirs. Even with radically different symptoms, many people with OCD suffer the same way. They get trapped in the same types of reassurance-seeking behaviors and mental rituals. They fall into similar patterns of avoidance. When you hear somebody else talk about their OCD — especially if it’s a different type of OCD — it can help you see your own OCD with fresh eyes, learn to take your own fears less personally, and ultimately relate to your own OCD in a different way. That’s one of the reasons why I so strongly advocate OCD support groups. Although we have to continue to educate the “I’m so OCD” people of the world, we’ve come a long way. There now exists a veritable army of OCD bloggers and OCDvocates, who have begun to candidly share their experiences with the disorder. They have written about what it’s like to live...
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Group Therapy for OCD: Power in Numbers

Group Therapy for OCD Wow. Our first OCD treatment group met yesterday, and IMHO, it was an incredible experience. Thank you to all who attended and showed such courage in standing up to their OCD. I was reminded anew how group therapy for OCD is so different than individual therapy. OCD wants to separate us from others, to shame us, to make us feel hopeless, defective, and guilty… It wants us to define ourselves on the basis of things we can’t control and forget that we are not our thoughts. After all, that’s how it maintains its power over us. Although there is great vulnerability in putting your thoughts out there and saying them aloud in front of others, by doing so, we defy our OCD. OCD lost a few battles yesterday. Let’s keep this war going. For those who missed our group, I hope you can join us next Saturday (8/17) at 1pm for our next session of group therapy for OCD. Upcoming OCD Treatment Group...
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OCD Treatment Group Using ERP

OCD Treatment Group! I am pleased to announce the availability of our new exposure and response prevention (ERP)-based treatment group.  The intent of this group is to provide a supportive environment for completing ERPs. Participants wishing to attend are required to register using the links at the bottom of this post. This group will first meet on Saturday (8/10/13), 1pm-3pm.  The fees for attending this group are $75/session or $50/session if you pay in advance and commit to a 4-week group treatment sequence.  Insurance will not be accepted; however, if you have out-of-network benefits, you may be eligible to submit your bill for reimbursement by your insurance company.  Subsequent 2-hour sessions will be held on 8/17, 8/24, and 8/31 @ 1pm. You are free to participate in any or all of these sessions; however, individuals are most likely to benefit from repeated exposure sessions. Because treatment is ERP-based, participants should be familiar with ERP for OCD and must be willing to complete exposures targeting their fear. As such, it might be most helpful to use this group to supplement your current self-directed or therapist-guided ERP program. You can read more about ERP here or in one of the many good self-help books about OCD. Due to the potentially sensitive issues that will be addressed in this group (e.g., harm obsessions, sexual obsessions, contamination and hygiene-related issues), participation will be limited to adults and mature teens who have obtained parental permission to attend.  Also, teens must be pre-approved by Dr. Seay. Individuals with all types of OCD are welcome to attend.  Participants are encouraged to bring exposure materials to this session (e.g., digital voice recorders, smart phones, contaminated objects, feared objects, notebooks for exposure, triggering pictures, etc.).  Exposures will primarily be self-directed but will be facilitated by Dr. Seay. Agenda Group Member Introductions Identifying Target Thoughts to Use in Exposure Exposure (45 minutes or longer) Debriefing & Goal-Setting In order to reserve adequate time for exposure, off-topic discussion will not be permitted. Future meetings will be announced via our Events calendar and email distribution lists.  Space is limited, so please secure your spot today by registering via the links below. Questions about this group should be directed to me (Dr. Seay) at (561) 444-8040.  The group will meet in my office in Palm Beach Gardens, FL. The address is 11641 Kew Gardens Avenue, Suite 207, Palm Beach Gardens, FL 33410....
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What is OCD?

OCD is a malevolent advisor that wants to deceive us about the fundamental nature of the world. It wants us to believe that the world shouldn’t have any sharp edges and that our experience should be as smooth and snag-free as possible. If snags are apparent, it tells us that we should exchange our current experience for one that is more perfect. Although nice in theory, embracing such a philosophy creates an impossible situation. After all, there is no snag-free world to inhabit. Even the best world is fundamentally flawed. The more we become preoccupied by the pursuit of perfection, the more hyperaware we become of life’s flaws. As Dr. Jon Grayson writes, as soon as we begin comparing anything real to the ideal, the real becomes intolerably cheapened in the comparison. Reality, no matter how good, can never live up to the fantasy. OCD is one of the most variable and least variable of all the DSM diagnoses. It’s incredible in its symptomatic diversity; no two individuals experience OCD in exactly the same way.  At the same time, OCD is remarkably consistent across domains when considered from the vantage point of wishes. All symptoms involve wishing for something that is impossible: wishing for perfect certainty, wishing for perfect safety, wishing for that perfect feeling…  When wishes alone do not suffice, rituals allow the sufferer to try to manifest the wish in the real world.  Although these rituals are well-intentioned, they are ultimately malignant. Sometimes the only way to live a good life is to give up the wishes and learn to accept and co-exist with life’s imperfections. Questions?  Comments?  Thoughts about the fundamental nature of OCD?  Sound off...
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Scary Thoughts as Costumes: The Illusion of Danger

It’s nearly Halloween, and kids around the country are digging through dusty closets and plundering the aisles of local Halloween shops in search of the perfect costume. Halloween is the one night of the year when we give ourselves permission to be silly, scary, or fantastical. We can act a little weird, and nobody will disapprove. On Halloween, it’s normal to see the ghastly holding hands with the divine; fairy princesses walk amongst zombies, lions, and super heroes. There is something thrilling about handing over the reins to your imagination…even if it’s only for a single night. But what would happen if the masks got stuck? What if every goblin remained a goblin and every ghost remained a ghost? The children underneath the make-up would still be our children, but their appearance would remain altered. How would we feel then? At first, it would be scary to inhabit a world populated by monsters. We would be angry. We would be confused. However, eventually we would learn to distrust our senses in the knowledge that beneath every scary facade is simply a child. Despite appearances, there is no danger here. We might wish that things could go back to the way they used to be, but eventually we would accept this new world as our reality. Sometimes our thoughts like to play dress-up, too. Scary, unwanted thoughts can masquerade as truths. Possibilities can take on the form of probabilities. Although these thoughts may have the appearance of danger, their form is intended to deceive. The semblance of danger is not danger. In the real world on Halloween night, beneath every sheet, mask, or painted face is a smile. Beneath every scary thought is simply a person. *     *     *Read more about OCD and unwanted thoughts,be it in the context of sexual thoughts, violent thoughts, or religious...
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Vomit Phobia – Fear of Vomiting (Emetophobia)

Flu season will be quickly upon us and with it comes an unfortunate increase in the likelihood of experiencing fevers, coughs, runny noses, vomiting, and the like. Although no one enjoys being sick, this time of year poses particular challenges for individuals suffering from “vomit phobia”, or emetophobia, the fear of throwing up. The fear of vomiting can affect individuals of all ages. It sometimes emerges in childhood and, if untreated, may follow a relatively chronic course. However, it can also develop well into adulthood, sometimes taking root after a negative health experience (e.g., after getting food poisoning or after experiencing an episode of severe or uncontrolled vomiting). Vomit Phobia in Children and Teens Consequences associated with the fear of throwing up can be extreme. In children, vomit phobia can lead to school refusal and avoidance. Academic performance may suffer, and children may miss out on certain developmentally important social milestones. If a child or teenager is afraid of getting nauseous or throwing up, he or she may avoid birthday parties, sleepovers, dating, and eating out at restaurants. Missing out on these activities can affect relationships and impact social development, which may lead to chronic social impairments. Even when longstanding social problems do not develop, children with vomit phobia still experience a great deal of unhappiness, fear, anxiety, and distress. Fear of Vomiting in Adults Adults with the fear of vomiting may also be significantly impaired by their symptoms. They may have more absences from work and may avoid work-related travel, which can affect opportunities for advancement. They will often dread meetings, during which they may feel trapped and uncomfortable, and may avoid certain job responsibilities like public-speaking or presenting.  This can leave otherwise bright and capable individuals stagnating in jobs that are beneath their true capabilities. Vomit phobia also affects travel for leisure and dining out, and can wreak havoc on romantic relationships. Women with the fear of vomiting may experience extreme distress at the thought of becoming pregnant and experiencing morning sickness. Women with the fear of morning sickness may delay starting families, and some may choose to never have children at all due to the fear of recurrent vomiting during pregnancy. Clearly, this can have profound and lasting effects on one’s life. What is Emetophobia? Emetophobia is defined as an excessive or irrational fear about the act, or possibility, of vomiting. However, this relatively straightforward definition...
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Postpartum OCD – Fear of Harming Your Baby

Parents brace themselves for many changes when a new baby comes home. As new routines replace old, life quickly becomes a confusing jumble of cherished memories, bottles, and dirty diapers. Parenting can be joyful, but it can also be terrifying. Parenting comes with many important responsibilities, and it can be intimidating–if not downright frightening–to be responsible for protecting and caring for a vulnerable new life. What is Postpartum OCD (ppOCD)? For some parents (mothers and fathers alike), new parenthood may spark postpartum obsessive-compulsive disorder (OCD), a surprisingly common anxiety disorder that is associated with violent and disturbing thoughts, images, or urges (Fairbrother & Abramowitz, 2007). Symptoms may begin suddenly after the new baby arrives home, or pre-existing OCD symptoms may be exacerbated by new parental responsibilities. Postpartum OCD symptoms can involve virtually any type of OCD symptom, but harm obsessions and sexual obsessions are especially common. Harm obsessions may include fears of accidental harm or intentional harm coming to the infant. Postpartum OCD – Unwanted Violent Thoughts Consider the mother of a colicky young infant who, frustrated by her baby’s crying, has a mental image of herself throwing her baby down the stairs. This thought occurs unexpectedly and feels dangerous, and the woman becomes extremely upset by this thought. This mother might think: “Why am I having this thought? Does this mean I might harm my baby? What if I lose control and throw my baby down the stairs? Mothers shouldn’t have thoughts like this.” In response to these thoughts, the mother may avoid going near staircases while holding her infant or may hold her baby extra tightly whenever she is near the stairs. She may become especially fearful of caring for her baby whenever it is crying, for fear that she might do something impulsive or dangerous. If certain parenting activities feel especially risky, these responsibilities may be delegated to other caregivers. Postpartum OCD – Unwanted Thoughts About Danger or Accidents Another common type of postpartum OCD symptom is the recurrent, intrusive fear that something bad has happened to the baby. For example, a parent might experience recurrent thoughts or intrusive images of their baby choking or suffocating in their crib. This parent might think: “It’s my responsibility to prevent any harm from coming to my child. If I have a dangerous thought, it’s important that I check every time just to make sure my baby’s okay. After all,...
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IOCDF Conference, IOP for OCD Program, & Group Therapy for Panic…

Just a few quick announcements: 1) The 2012 meeting of the International Obsessive-Compulsive Foundation (IOCDF) is just a week away. The IOCDF conference marks the perfect convergence of all things OCD-related. In attendance are some of the best clinicians and researchers in the field.  Many of these individuals will be presenting talks related to OCD diagnosis and treatment. Hundreds of individuals with OCD will also be at the conference, some of whom will be leading workshops and sharing stories of recovery. This year’s roster of presentations looks to be exceptional. If you haven’t registered yet, there’s still time. This year’s meeting will be held in the Windy City: Chicago, Illinois. I’ll be attending–hope to see you there! Also…I may try to be more active on Twitter during the conference.  Feel free to follow me here. 2) I have revamped the description of my Intensive Outpatient Program (IOP) for OCD and have posted an updated summary page on my practice website. This program is not for everyone…but is appropriate for: Local OR out-of-town patients (with any level of OCD symptoms) who wish to complete treatment in the shortest amount of time possible. Individuals who have stubborn symptoms of OCD that have not responded well to traditional outpatient therapy. Individuals with severe symptoms who are seeking an alternative to residential treatment or to psychiatric hospitalization (inpatient treatment). We offer specific programs for adults, kids, and teens.  Click the above link to access the program description. 3) In other news, I’d like to announce that I’ll soon be starting a 6-week, CBT-based group therapy treatment program for panic disorder. This group is designed as an introduction to cognitive behavioral therapy for panic. Although you won’t be panic-free in 6 weeks, you’ll have some of the basic skills and knowledge you’ll need to kickstart your recovery.  Moreover, because this intervention is a  therapy group, you’ll get to work alongside others with similar symptoms. Till next time… Questions? Comments? Will you be at the 2012 IOCDF Conference in Chicago? Sound off...
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Suicide Obsessions: Fear of Killing/Harming Yourself

Thoughts of death, dying, and suicide are an unfortunate reality for many individuals. In the U.S. alone between 2008 and 2009, approximately 3.7% of adults (8.3 million Americans) reported having suicidal thoughts (Crosby et al., 2011). During that same time frame, approximately 2.2 million U.S. adults reported making specific plans to commit suicide. An estimated 1 million Americans attempted suicide, and 36,035 individuals died as the result of suicide. Clearly, suicidal thoughts and actions impact a significant number of Americans. Although suicidal thoughts are most often associated with depression, suicidal thoughts are not experienced exclusively by those who are clinically depressed. Suicidal thoughts may also accompany other mental health conditions and may even occur in healthy individuals in the general population. Not all thoughts related to suicide pose the same level of risk. Suicidal thoughts can range in intensity. Some thoughts may be fleeting, whereas others may involve detailed planning of the suicidal act. In addition to variations in the level of danger associated with different types of suicidal thoughts, some individuals may be at a greater/lower risk for acting on their thoughts. Suicide obsessions are a specific category of suicidal thoughts that are unique to individuals with OCD. If you’ve read my previous posts on harm obsessions, you might conceptualize suicide obsessions as aggressive obsessions directed inward. Suicide obsessions involve repetitive, unwanted thoughts of suicide that cause severe distress. In contrast to other types of suicidal thoughts, suicide obsessions are symptoms of OCD that do not reflect a “true” intention to kill or harm oneself but rather reflect a repetitive thought loop that gets stuck. Suicide obsessions can occur spontaneously, seemingly out of nowhere, or may be triggered by unpleasant (or even pleasant!) activities. These repeated, unwanted thoughts about death, suicide, or self-harm may occur many times throughout the day. Not all obsessions in this category involve death. Some individuals have unwanted thoughts involving self-injurious or self-mutilating behaviors, which instead might be more accurately referred to as “self-harm obsessions” rather than “suicide obsessions.” Suicide Obsessions & Self-Harm Obsessions Here are some common examples of suicide and self-harm obsessions. Fear of committing suicide in the absence of a desire to do so (e.g., fear of slitting your wrists, hanging yourself, or overdosing on medications). Fear of becoming depressed and then feeling compelled to commit suicide. Fear of jumping off of a building or another high place. Fear of stepping...
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Fear of Hurting Other People

The fear of harming others can be a sign of obsessive-compulsive disorder (OCD), a neurobiological condition that is associated with repetitive, intrusive, distressing thoughts that can’t easily be dismissed. Fear of Harming Other People On Purpose Some aggressive obsessions involve the fear of harming others intentionally. In my last post about the fear of hurting other people on purpose, I identified several specific examples of harm obsessions. These included the fear of losing control and murdering your child, the fear of stabbing a loved one, and a variety of other fears involving violent, murderous, or criminal acts. Fear of Harming Other People By Accident Other harm obsessions involve the fear of causing accidental harm, usually through negligence or carelessness. Individuals with these fears often feel that if they notice a situation that might be dangerous or harmful, they are morally obligated to act “responsibly” in order to avert potential danger. Many years ago, I treated a student who would carefully remove all sticks, rocks, and other assorted debris from the sidewalks and hallways leading to and from his classes.  He felt that if he noticed a rock that could potentially cause someone to trip and fall and did not move it out of the way, he would be responsible if someone got hurt.  This was further complicated by the fact that the floors in the student’s school were very scuffed and worn, and it was hard to tell the difference between scuffs and actual debris. Because of this, he felt compelled to kick each scuff just to make sure that it wasn’t really a stick or rock. Before treatment, on good days, the process of walking to class took many minutes.  On rough days, it could take hours…causing him to be late or miss class entirely. For this individual, and for many other people with OCD who fear harming others through negligence, an inflated sense of responsibility leads one to take excessive precautions and to be conscientious to the point of sacrificing one’s own welfare. For some people, failing to prevent harm can feel almost as bad as causing that harm directly. Other situations where people worry about causing harm through negligence include the following… Fear of Accidentally Hurting Other People (Examples) Fear of insufficiently cleaning dishes, pots and pans, baby bottles, toys, or cooking/cleaning surfaces, which might result in illness or death. Fear of accidentally contaminating food with...
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Aggressive Obsessions: Fear of Harming or Killing Others

Aggressive obsessions go by many names. Harm obsessions, violent obsessions, morbid obsessions…the list goes on… These symptoms of obsessive-compulsive disorder (OCD) involve the fear of harming or killing other people. In other cases, aggressive obsessions are directed at the self, such as when individuals experience unwanted, intrusive, and recurrent thoughts about hurting or killing themselves (suicide obsessions). This post will focus on aggressive obsessions that involve the fear of harming or killing other people. Aggressive obsessions involving suicide and self-harm will be addressed in a subsequent post. Fear of Harming or Killing Others Aggressive obsessions often focus on violent, murderous (stabbing, shooting, choking, poisoning), or criminal (arson, bank robberies) acts and involve graphic mental images of blood, injury, and death. Individuals with violent obsessions may fear becoming serial killers or deliberately hurting someone they love. Aggressive obsessions affect individuals of all ages, including adults, adolescents, and children. Common examples include: Fear of going on a murderous rampage, involving stabbing or cutting. Fear of grabbing a nearby policeman’s gun and shooting someone. Fear of choking your baby or partner to death. Fear of snapping your child or pet’s neck. Fear of pushing or throwing someone off a building or other high place. Fear of intentionally poisoning someone (e.g., putting rat poison into your loved one’s food). Fear of hitting, striking, or beating someone to death. Fear of pushing/throwing someone down the stairs (e.g., babies). Fear of walking up behind someone and slitting their throat. Fear of smothering your baby or partner while they are sleeping. Fear of drowning your child while swimming or giving him/her a bath. Fear of committing a bank robbery. Fear of committing arson. Fear of getting angry and shaking your child to death. Fear of side-swiping and killing a pedestrian or cyclist while you are driving. Fear of aggressively pushing your grocery cart into other shoppers who are in your way. When riding in the car as a passenger, fear of grabbing the steering wheel and causing an accident. Fear of putting your baby or pet into an oven, microwave, washing machine, or clothes dryer. Similar to what occurs in the case of sexual obsessions, individuals with aggressive obsessions are often afraid of acting on unwanted impulses.  However, sometimes violent obsessions are not associated with urges to act. In such cases, symptoms may consist of unwanted thoughts or vivid, disturbing mental images of violent behaviors. Individuals...
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Harm Obsessions & Violent Obsessions

Imagine that you’re leaning down to kiss your young daughter goodnight, when BAM! You are jolted by an image of yourself stabbing her to death. Alternatively, picture yourself as a young child who is intensely afraid of playing with your new puppy…not because you’re afraid of dogs but because you are afraid that if you touch it, you might lose control and snap its neck. In either scenario, the most horrifying part is that you’re afraid that you might secretly want to act on these unwanted thoughts. After all, why would the thought keep coming if it didn’t mean something? Violent Obsessions, Harm Obsessions, & Bad Thoughts This is the daily reality for many adults, teens, and children who experience harm obsessions, also known as violent obsessions, a type of OCD symptom that involves unwanted, repetitive violent thoughts, impulses, or images. Harm obsessions are typically shocking, distressing, and disturbing, and they may occur thousands of times every day. They often involve themes of violence, death, murder, self-harm, and suicide. Obsessions involving death are also sometimes referred to as “morbid obsessions.” Much like sexual obsessions, violent obsessions can be a debilitating symptom of OCD because they can “pop in” at any time and in any place. They are sometimes associated with the presence of triggers like particular people (e.g., loved ones) or vulnerable populations (e.g., children or the elderly), but they may also occur with strangers. In other cases, they may seemingly emerge out of the blue with little provocation or warning. They can even occur when you’re alone or in the absence of an easily identifiable external trigger. Because of this, many people with violent obsessions begin avoiding people they care about. They may also become fearful of being alone or being bored and may go to great lengths to keep themselves busy, because their unwanted thoughts may frequently occur during periods of downtime or relaxation. Consequently, many individuals with harm obsessions feel that they can never really relax. They become masters at distraction and often dread bedtime when they are alone with their thoughts. Who gets violent obsessions? Unfortunately, most people in the general population are unfamiliar with harm obsessions. Popular TV shows like Glee that feature characters with OCD (e.g., guidance counselor Emma) do not often depict individuals with violent obsessions. Even medical professionals like doctors, nurses, or mental health workers may not initially recognize the fear...
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OCD & Checking: Part 2 (Mental Checking)

Behavioral Checking (Overt Checking) Many examples of compulsive checking rituals in OCD involve direct inspection of a target stimulus by sight, sound, or feel. Common OCD checking behaviors include relocking doors, visually examining the position of one’s parking brake, or holding one’s hands above stove burners in order to detect warmth. Behavioral checking is often accompanied by the thought, “Did I do it the right way?” These checking behaviors are often referred to as behavioral checks, manual checks, or overt checks. Overt rituals (by definition) are visible behaviors that can be perceived by external observers. However, in some cases, overt rituals may be subtle or purposefully hidden in order to avoid embarrassment. Mental Checking (Covert Checking) In contrast, other compulsive checking rituals can only be perceived by the individual engaging in the behavior. These types of OCD rituals are thought-based and are sometimes referred to as mental checking or covert checking rituals. Mental checks are often accompanied by thoughts such as, “Did I do it the right way?”, “Am I feeling the right way?”, or “Did I do this for the right reason?” Mental checking is the cognitive counterpart of behavioral checking, and many covert checking rituals overlap extensively with the mental rituals that characterize Pure-O OCD. Whereas overt checking involves obtaining evidence directly from the current physical environment (i.e., obtaining visual, auditory, or tactile feedback from physical objects or behaviors), mental checking typically involves an evaluation (or reevaluation) of information already obtained. This information may exist in the form of memories, feelings, motivations, or other internal states of being. Mental checks can occur both in the presence and absence of a given target stimulus. Individuals may engage in mental checking rituals shortly after an event, but covert checking is not bound by time or space. Some people with OCD continue to check hours, days, or even years after the original event. For example, some individuals may review or check the content of conversations that occurred many years ago. Let’s identify some examples of mental checking. This list is not exhaustive but is intended to illustrate the diversity of situations in which mental checking might be present. Examples of Mental Checking 1. Memory Checking Rituals – Reviewing one’s memory to “make sure” or verify that a behavior was completed properly. Did I lock the door?  Was the stove really off? Was the “H” on the faucet handle facing the...
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Checking & OCD: Part 1 (Checking for Safety)

Compulsive checking often begins innocently enough. One check here, two checks there… But OCD’s greed knows no bounds. What starts out as a simple check “just to make sure” eventually spirals into disabling OCD doubt that can come to predominate innumerable situations and scenarios. Checking behaviors often emerge in situations in which “being irresponsible” might result in catastrophic outcomes, guilt, anxiety, or regret. OCD-related checking is usually driven by a need to obtain absolute certainty that nothing bad will happen. Compulsive checking is typically harder to control in “high stakes” scenarios and in situations in which you perceive that you have personal responsibility for the outcome. Unfortunately, at least some degree of personal responsibility is present in most situations. Moreover, many people with OCD often feel that safety is tenuous or that disasters are lurking just one mistake away. Consequently, people with severe checking-related OCD may experience very little solace in their day-to-day lives. Compulsive checking behaviors are probably the most diverse of all OCD rituals. Variations in checking-related behaviors dominate in most forms of OCD, even types of OCD that you might not necessarily consider checking-related variants of the disorder (e.g., hit-and-run OCD, scrupulosity, perfectionism, HOCD, other sexual obsessions). In this multi-part post, we’ll talk about some of the goals of checking and the different types of situations in which checking-related symptoms are present. We’ll begin by discussing OCD checking compulsions related to safety/danger. OCD Checking for Safety/Danger When people think of checking-related OCD, they most often think of situations that involve issues of potential danger. People who check for safety may check locks, stoves, light switches, or virtually any appliance or item with an electrical cord. Other common household items that are commonly checked include toasters, washing machines, dryers, ovens, curling irons, coffee machines, computers, televisions, candles, and fireplaces. Thoughts that often drive these types of compulsive OCD checking behaviors are fears of fires, which may destroy homes or result in injury or death. Some individuals with anxiety about safety issues have very restricted, specific fears. For example, some individuals fear that their “careless” behavior will result in the death of a beloved pet. Some people with safety-related OCD think, “If I have a thought and don’t take preventative action, then that’s almost as ‘bad’ as directly causing the feared outcome myself.” Others think, “If I have a thought and don’t do whatever I can to eliminate...
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HOCD: Homosexual OCD & Sexual Orientation OCD

Fear of Being Gay (Homosexual OCD / HOCD) Emerging sexuality can be confusing for any teen or young adult, and gay teens face a variety of unique challenges over the course of adolescence. In addition to learning to understand their own sexuality, gay teens must navigate complex situations and pressures that may not be relevant for straight teens. They must also deal with opinionated parents, friends, and others who sometimes hold differing views about sexuality. Anxiety, distress, and confusion are often part of this process. This post is not about the anxiety associated with being gay or with “coming out” but instead discusses homosexual OCD (“HOCD”), an anxiety disorder that affects a small number of individuals. HOCD is not unique to teens but can occur at any age. What is HOCD? Homosexual OCD (“HOCD”) is a specific subtype of obsessive-compulsive disorder (OCD) that involves recurrent sexual obsessions and intrusive doubts about one’s sexual orientation. Straight individuals with homosexual OCD experience obsessive fears about the possibility of being gay. Their HOCD obsessions often consist of unwanted thoughts, impulses, or images that uncontrollably pop into consciousness. To reduce the anxiety brought on by their obsessions, individuals with HOCD engage in a variety of rituals that focus on “proving their true sexuality” or reducing their perceived “vulnerability” to becoming gay. Sexual obsessions can also affect gay men, lesbians, or bisexual individuals with OCD, who may become fearful about the possibility of becoming straight (“Straight OCD”). The common element that unites these seemingly opposite sexual obsessions is the fear of being attracted to something unwanted, taboo, or “unacceptable” based on one’s particular worldview. For the sake of simplicity, I’ll be using HOCD-centric language in this post. However, the same basic elements are directly applicable to all people with obsessive doubts about their sexual orientation. People with HOCD worry that they might secretly be gay or might become gay, despite not questioning their sexuality in the past. Prior to the onset of HOCD, they might have had few doubts about their sexual orientation. Many people with homosexual OCD also have a history of having enjoyed heterosexual relationships in the past.  It was only after the first unwanted thought “popped” that they became overly concerned about the prospect of being gay. The occurrence of this unwanted thought then causes them to question their sexual identity and reanalyze previous experiences, in light of the possibility that...
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Sexual Obsessions in OCD (Obsessive-Compulsive Disorder)

Sexual obsessions in OCD are recurrent unwanted sexual thoughts, such as the fear of being attracted to something unwanted, taboo, or morally “unacceptable” based on one’s particular worldview.  Although all forms of OCD can be debilitating, sexual obsessions can be especially confusing and disabling for sufferers because sexual obsessions target one’s fundamental identity as a social being. In addition to anxiety, which characterizes most obsessions, individuals with sexual obsessions often experience extreme guilt, shame, hopelessness, and depression.  Individuals with OCD with sexual symptoms often mistakenly consider themselves deviant, disgusting, or evil. Moreover, incorrect assumptions about the true causes of their unwanted sexual thoughts make them less likely to seek treatment or to share their symptoms with others.  In my Palm Beach County, South Florida psychological practice, I treat many individuals who have lived with sexual obsessions for many years before seeking treatment. Sexual obsessions often leave one feeling isolated and alone.  Moreover, in efforts to avoid symptom triggers, people with unwanted sexual thoughts often drop out of school, quit their jobs, end relationships, or make other life-altering decisions that paradoxically make their symptoms worse. What are Sexual Obsessions? Sexual obsessions in OCD can take many forms. Most sexual obsessions involve unwanted thoughts, ideas, impulses, or images focusing on sexual content.  Some individuals with sexual obsessions are bombarded by unwanted urges to act in a sexual way toward children, animals, or other populations.  They might experience intrusive images of sexual organs, envision themselves performing unwanted sexual acts, or have persistent doubts about their own sexual identity. They experience repetitive thoughts like: What if I’m attracted to that person? What if I lose control and act out sexually? What if I expose my genitals to that person? What if I secretly want to have sex with that person? Sexual obsessions often involve the fear of secretly being gay (if one is actually straight), being sexually attracted to children (fear of pedophilia), being sexually attracted to animals (fear of bestiality), or being sexually attracted to dead things (fear of necrophilia).  In fact, the variety and forms that unwanted sexual thoughts can take are limited only by the breadth of the human imagination. Societal and personal beliefs about these topics often lead to extreme distress whenever these obsessions occur.   Here are some common sexual obsessions / thoughts. Types of OCD Sexual Obsessions / Thoughts Fear of being a pedophile or becoming a pedophile. (parents often...
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Worry & “What If” Questions

Anxiety, Worry, & What If Questions If you have anxiety, it’s likely that you wrestle with worry and “what if” questions. Many what if questions are easily recognizable and start with the obvious, “What if…?” Others are more subtle and begin with phrases like “How am I ever going to…?” By definition, what if questions prompt us to solve problems that haven’t actually happened yet. The possibilities are truly endless. These worries may involve fears about current situations or about situations set far in the future. What if questions are often difficult to resist because by answering them, we often feel that we become more mentally “prepared” or “ready” to deal with life’s uncertainties. In fact, many individuals feel stressed out if they ignore their worries. They think that because what ifs involve potentially dangerous situations, it’s irresponsible or reckless to ignore these worries. By answering what ifs, they hope to have a better degree of control if and when these situations actually arise. Many individuals with anxiety disorders like obsessive-compulsive disorder (OCD) or generalized anxiety disorder (GAD) struggle with what if questions and other worries for hours each day. How often does this “mental preparation” actually pay off for people with anxiety? Almost never. That’s because mental reassurance (a type of mental ritual) is capable of providing only transient relief. We may feel prepared for a few seconds, minutes, or hours, but the feeling eventually wears off and then we feel compelled to re-board the what if train. Because life involves infinite possibilities and our current situation is constantly changing, the scope of potential what if questions is limitless. You could literally spend the rest of your life preparing for every possible contingency in the hopes that you would be in a better position to deal with it (if and when it actually happens). However, you can never be fully prepared.  Perfect preparation is only a mirage. Providing specific answers to your anxiety’s what-if questions is like trying to fill a colander with water. You can spend time doing it, but it’s never going to get you anywhere. Moreover, you’ve wasted a lot of water in the process. Similarly, there are consequences to answering what ifs. What are the consequences of answering what if worries? Answering what if questions substitutes thoughts for action. Because only action can create lasting change, answering what ifs is an avoidance behavior. Time spent...
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Hit-and-Run OCD

“Hit and run” OCD involves the fear of accidentally hitting a pedestrian while driving.  In most cases of hit-and-run obsessive-compulsive disorder, fears focus on unintentionally killing, injuring, or maiming a victim.  Other individuals worry about causing car accidents or causing other vehicles to swerve and hit pedestrians. Fear of Driving Hit-and-run OCD, or motor vehicle accident OCD, is distinct from other syndromes that involve anxiety about driving or the fear of car accidents. Hit and run OCD differs from panic– or agoraphobia-related driving avoidance, in which individuals fear driving due to the possibility of having a panic attack while in the car. Diagnosis of hit and run OCD is slightly more complicated in cases in which one fears “losing control” while driving, as this symptom can reflect either panic or OCD. In the case of panic, this fear is based on panicking and “losing control” or “going crazy”, whereas in OCD this fear is based on acting on an unwanted impulse (e.g., impulsively swerving). Hit and run OCD differs from “driving phobia” largely in terms of the rituals/compulsions that are present in OCD. Driving phobia involves more generalized fears. MVA-OCD also has a different symptom profile than post-traumatic stress disorder (PTSD) which might develop following a car accident and include flashbacks and other PTSD symptoms. Symptoms of “Hit and Run” OCD Hit-and-run OCD resembles other forms of checking OCD.  Just as checking a stove is used to prevent fire, checking for accidents while driving is a way of preventing (or reducing the severity of) accidental injury or death.  A common form of checking is driving back along the same route in order to scan for victims. Unfortunately for sufferers, this compulsion actually creates yet another opportunity for having caused an accidental death or injury.  Despite driving along the same road multiple times, the potential for having missed something remains.  Relentless OCD doubt and uncertainty persist.  Many individuals get stuck in checking loops that span many minutes or hours until exhaustion and/or distress make further checking impossible. Symptoms of hit and run OCD are time-consuming, distressing, and often debilitating.  Let’s review some of the most common symptoms of hit and run obsessive compulsive disorder (OCD). Common Rituals in Hit-and-Run OCD Similar to other forms of checking OCD, hit-and-run OCD involves checking and reassurance rituals. These rituals include: Circling back and checking for victims/bodies. Looking in the rear-view mirror for signs...
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Scrupulosity

What is Scrupulosity? Scrupulosity is a form of obsessive-compulsive disorder (OCD) characterized by religious and/or moral obsessions. Scrupulosity can sometimes be difficult to recognize because even within a single faith community, religious beliefs and practices vary widely. There is no singular belief or behavior that is diagnostic for scrupulosity. Instead, scrupulosity is best regarded as a pattern of beliefs and behaviors associated with excessive worry about having committed a sin or engaging in immoral acts. Concern may focus either on thoughts or actions already taken or the possibility of committing sins in the future. This results in significant emotional distress, guilt, and despair. Scrupulous individuals also worry about the sinfulness of having bad thoughts. This experience is very similar to individuals with OCD who experience harm-related obsessions (e.g., the fear of harming a child or loved one). People with scrupulosity often wonder why they’re having bad thoughts and worry that these thoughts have special meaning. They also mistakenly assume that they wouldn’t be having these thoughts if the thoughts weren’t true. Because the sinfulness of thoughts is discussed in the Bible and other religious texts, many scrupulous individuals take this as “proof” that they should be able to control their thoughts at all times. For individuals who hold this belief, it is especially important that treatment includes steps related to belief clarification. Treatment of scrupulosity may also include consultations with religious professionals. When I treat individuals in South Florida (Palm Beach Gardens, West Palm Beach, Jupiter) with scrupulosity, I typically incorporate these elements in my treatment plan. Feared consequences associated with scrupulosity often focus on damnation, estrangement from God, making God angry, or living an empty existence. There may also be the fear that one may “corrupt” others or experience uncontrollable feelings of guilt forever. In order to prevent these outcomes from occurring, individuals with religious scrupulosity engage in a variety of rituals. These compulsions typically involve taking preventative action to keep a sin from occurring or engaging in some type of restoration ritual to repair their relationship with God. People with scrupulosity also commonly engage in a variety of mental rituals. How is Scrupulosity Diagnosed? Diagnosis of scrupulosity is complicated because symptoms of scrupulosity exist at the intersection of spirituality and mental health.  This results in symptoms of scrupulosity frequently going undetected. Psychologists may not sufficiently inquire about one’s faith tradition and overlook scrupulous symptoms.  Similarly, religious professionals...
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Scrupulosity & OCD: Religious/Moral Symptoms

Question: I have scrupulosity (religious/moral obsessive-compulsive disorder), and I am triggered by religious posts on Facebook. When I see a religious post, I feel like I have to repost it or God will be mad at me. I also worry about what other people think about these reposts, which then leads me to fear that God will judge me for worrying. Any suggestions for treating scrupulosity (religious OCD)? Religious Scrupulosity/OCD For many people with OCD/scrupulosity, treatment can be especially confusing at first. Every action or inaction can feel potentially dangerous, which is why scrupulosity often goes untreated for so long. The very fact that you recognize that this is related to obsessive-compulsive disorder is excellent. It also sounds like you have insight about your OCD symptoms and the OCD positive feedback loop. Many people with religious obsessions don’t realize that obsessions can target religious/moral topics. Their OCD tells them that it’s impossible to engage in religious practices “too much” or “too frequently.” Scrupulosity/OCD Belief Clarification The first step in your recovery is to clarify your religious beliefs. If you don’t do this, exposure and response prevention for your scrupulosity will likely be unhelpful. The types of questions you should ask yourself are: Does God expect me to be perfect? If I make a mistake or commit a sin, does my religion have procedures for obtaining forgiveness? Would God want my behaviors to be largely driven by obsessive-compulsive disorder? Would God want my relationship to my religion to be OCD-based or faith-based? Would God understand what’s going on in my head and want me to fight my OCD? If my treatment involves doing things that might be considered potentially sinful, would God understand? Although you cannot have complete confidence when answering many of these questions, your answers to these questions will help frame your treatment efforts. For those whose symptoms distort their view of God, these questions can be especially tricky. These individuals sometimes base their answers on how they would like to think about God. When I treat people who have religious scrupulosity in my South Florida (Palm Beach County) psychological practice, my intention is not to change their religion or create more guilt for them…but rather to help them determine if there are aspects of their current relationship to God/religion that are dysfunctional. If this is the case, it’s not the person’s fault; this simply reflects a common...
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Exposure and Response Prevention: An Analogy

Exposure and Response Prevention (ERP) Exposure and response prevention (ERP) is just like a fitness program for your brain. However, instead of shaking up your fitness level, it’s designed to shake up stubborn OCD symptoms. Let’s expand on this analogy. Reasons for Doing Exposure and Response Prevention (ERP) People don’t adopt fitness routines for no reason at all; physical exercise is not a random activity. We don’t accidentally buy gym memberships or wake up on treadmills. Exercise is always purpose-driven and typically is intended to improve one’s quality of life in some quantifiable way. Common goals for exercising are related to health, aesthetics, or the feelings it evokes. Treatments like exposure and response prevention (ERP) are also intended to enhance your life in a meaningful way. Just like with exercise, your ERP efforts will be driven by your own personal motivators. Maybe you want to spend less time on your rituals so that you can be living more deliberately and less reactively. Perhaps OCD has caused your world to shrink, and you want to take it back. Maybe you’re motivated to fight OCD so that you can be a better parent or spouse. Maybe you simply want your days to be filled with more fun and less panic. These reasons form the basis of your recovery plan. If these reasons don’t exist for you…if you’re doing treatment for someone else rather than for yourself, the road will be difficult. In order to be able to sustain effort through challenges, you will have to identify personal motivators that are meaningful to you. Just like with physical exercise, your ERP has to be purpose-driven or you will lose your momentum. This analogy can be taken even further. Exposure therapy is not a singular activity. Physical exercise is often based around targeting a particular muscle group or certain aspect of health. People who want big biceps do different exercises than people who want to lose weight. This is similar to exposure and response prevention therapy. People who want to be less bothered by unwanted thoughts (e.g., thoughts of hitting someone with your car) do different exposures than someone who is afraid of contracting a deadly disease. The form of the “exercise” reflects a specific therapeutic goal. You can target your OCD symptoms in multiple ways. People who want to work on their abs might consider crunches, leg lifts, push-ups, etc. In ERP,...
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Starting Exposure Therapy: What’s it Like?

For anyone new to exposure-based therapy, such as exposure and response prevention (ERP), there is often much anticipatory anxiety about starting treatment. “What is it? What will it be like? How bad will it be? Can I handle it? Will I be forced to do things I’m unwilling to do?” These uncertainties are typical for most people beginning the process. They’re also understandable. When you begin treatment, it often feels like you’re putting your fate in someone else’s hands. Because that someone is typically a stranger (i.e., your therapist), it would be a bit odd if you didn’t feel that way. Moreover, if you know the basics of exposure therapy, you understand that eventually you’ll be confronting the very things you fear. Some people accept this prospect with dread but others feel a sort of nervous anticipation. Although they expect that treatment will be challenging, they also realize that life without treatment is often more challenging. Starting therapy is a calculated risk. Sure, it’s possible that treatment will be hard. However, it’s probable that life without therapy will be hard. If you remember the old Choose Your Own Adventure books from the 80’s/90’s, you have a good idea about how therapy isn’t. If you or your kids were a fan of the series, you probably recall just how easy it was to fall into a ravine or get eaten by a pterodactyl. Death abounded at nearly every turn.  There was usually only one way to get the “right” ending, and I for one could usually only discover it by reading the book backwards and cross-referencing the pages in order to see how the story “should” unfold. With these books, one mistake could totally derail the ending. Therapy isn’t like that. Sure, there are some potential “traps” that are better off avoided.  However, most of these traps involve rituals, and once you get better at spotting your rituals, the process gets easier. Treatment doesn’t lock you into a predetermined linear path.  Instead, it helps you become better at recognizing when you’re at a decision point. It then supports you in making choices that reflect your values rather than your symptoms.  Because this is a skill-based process, you learn to make better decisions over time. You transform from pterodactyl prey to pterodactyl hunter. Unlike Choose Your Own Adventure books, therapy is a forgiving process; it doesn’t require perfection. Treatment gives you many potential...
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Treatment of Unwanted Thoughts & Sensations in OCD

In my post about the treatment of sensorimotor OCD, a reader asked about the ultimate goal of treatment. Should the goal of treatment be to never notice an unwanted thought or symptom? Suppressing Unwanted Thoughts & Sensations in Pure-O & Sensorimotor OCD Let’s explore this idea in detail. Suppose I adopt the goal of being 100% symptom free. After all, this is the endpoint of treatment that most people are seeking. What are the implications of this goal? You will likely slow down your progress. Why? Because every day you will encounter something that violates your expectations. Unwanted thoughts are a normal part of the human experience. Everyone has thoughts that are unwanted, aggressive, selfish, perverse, or deviant at times. For people without OCD, these thoughts tend to be fleeting because the thoughts themselves aren’t treated as significant. They are accepted as normal brain noise. These thoughts may register, but they quickly get buried beneath other more pressing or interesting thoughts. For people with Pure-O OCD, unwanted thoughts may occur over and over again. Often these thoughts are considered dangerous or preventable, or they may be regarded as problems in need of solutions. Many people with Pure-O OCD become emotionally invested in filling their heads with the “right” kinds of thoughts. It is largely the importance we attribute to our unwanted thoughts that determines whether or not they get stuck. As soon as we shift into problem-solving mode via a behavioral ritual or a mental compulsion, we increase the salience and power of the perceived threat. Rituals reinforce and sustain what-if’s, which is why rituals are so good at maintaining OCD symptoms over many days, months, and years. If you read my last post about thought control in OCD, you recognize that never having an unwanted thought is an impossible goal. Our brains just don’t work that way. If you insist on being symptom-free, “normal” body-noise and thought-noise becomes a potential threat. This is because it leads you to characterize something normal as unwanted and dangerous. If you think about it, you’ll realize that it is often not the actual occurrence of symptoms themselves that creates anxiety, but rather the personal ramifications of those symptoms. For people with Pure-O OCD, fear is often based on the possibility that having an unwanted thought means something about you (e.g., maybe you secretly want to harm a family member or maybe you’re...
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Thought Control & OCD (Obsessive-Compulsive Disorder)

OCD & Thought Control Can I learn to eliminate my OCD thoughts? I hear this question all the time from new patients who are searching for ways to suppress their unwanted thoughts. When I answer this question with a resounding “no”, there is often much surprise and grief. After all, this is why they’re coming to see me. Many people with Pure-O OCD imagine thought control to be the only way to improve the quality of their lives. Unfortunately, thought control conceptualized in this way is not an attainable goal in OCD treatment. Our brains just don’t work like that. I explain it like this, “A penguin obsessed with flying is an unhappy penguin.” Expecting thought control to work is a little bit like a penguin flapping its wings and expecting to fly. It may work for the other birds, but it won’t work for the penguin. The penguin’s wings are not designed to work this way. This doesn’t mean that penguins can’t be happy. It simply means that a penguin who becomes preoccupied with an unattainable goal is likely to experience a lot of unnecessary suffering. Our brains are not equipped to simply ignore situations we perceive as threatening. If you were walking in the woods and noticed a snake slithering up next to you, your brain wouldn’t allow you to just ignore it. Instead, it would come up with solutions for surviving the situation. Fight-or-flight is biologically-based. Because survival is critical, our brains are hard-wired to act quickly and aggressively to guarantee it. As much as you might wish to never have bad thoughts, you can’t change the way the human brain fundamentally works. There is a solution, however. It does not involve suppressing the thought or never having the thought in the first place. Instead, it involves becoming less afraid of your thoughts and learning to correct any threat misappraisals to which you might be vulnerable. If you’re a snake trainer, you have logged enough hours with snakes so that you’re much less afraid of them. You could even be around a whole nest of snakes and not break a sweat. Exposure and response prevention for OCD is a bit like becoming a master snake trainer. Your fear won’t evaporate overnight, but with practice you will learn to be more comfortable and less distressed by your thoughts. You’ll also get better at tolerating doubt and uncertainty....
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Fear of Saliva Swallowing & Choking: Treatment & Symptoms (OCD)

Question: I have sensorimotor OCD, and I’m suffering from conscious swallowing. My main fear is that I’ll choke or swallow my own saliva whenever I’m speaking or singing. Any tips for how to tackle this fear via exposure and response prevention (ERP)? Great question. Consistent with general exposure and response prevention (ERP) principles, your exposures need to address your specific feared outcomes. Feared outcomes can vary greatly for individuals with the same presenting problem. I discuss this idea in a different context here: feared outcomes in OCD. For people with a fear of swallowing or drinking saliva, there are several possibilities. Fear of Potential Embarrassment: Social Anxiety If you are afraid of potential embarrassment due to coughing or choking while speaking, your symptoms might actually reflect underlying social anxiety (rather than somatosensory OCD). However, it’s also possible for social phobia symptoms to coexist with sensorimotor OCD. I touched on the intersection of OCD and social anxiety in my post about the fear of cursing/swearing/blurting out obscenities. I also discussed it more extensively in my post on compulsive swallowing. Those posts describe somewhat different OCD symptom domains, but the social fears sound quite similar to what you’re describing. Social anxiety fears can be targeted via behavioral exposures that do not actually involve saliva swallowing. You might practice stuttering on purpose, tripping over your words, or “freezing up” intentionally so that it looks like you don’t know what to say. These examples of intentional mistake practice can help you become less frightened of the potential social consequences of getting interrupted while speaking or singing. Such exposures would also be appropriate for targeting perfectionism-related OCD obsessions. OCD Fear of Swallowing Saliva: Coughing/Choking OCD fears based on saliva swallowing itself can also be tackled directly through non-avoidance and exposure exercises. For example, you might practice having conversations and/or singing with spit in your mouth. Your goal should be to resist rituals (i.e., compulsions) that involve clearing your mouth of excess saliva. During these exposures, don’t let your fear of coughing/choking cut your interactions short. Coughing and choking can be uncomfortable but these symptoms are not dangerous. When you do cough, it is critical that you continue with the conversation. If you stop your exposure upon choking or coughing, you run the risk of inadvertently strengthening your fear. Always continue the exposure until your anxiety has decreased significantly. Other creative OCD exposures might involve...
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Reassurance Seeking in OCD

Although contamination OCD and washing rituals often go hand-in-hand, many rituals in this domain do not actually involve cleaning or disinfecting. These more subtle rituals are often based around reassurance seeking behaviors that become ingrained in everyday habit. In the context of exposure and response prevention (ERP), reassurance seeking OCD rituals are just as important to address as washing rituals. If you resist washing rituals but continue to engage in reassurance seeking rituals, your recovery will eventually stall (or perhaps never get started at all). Do you believe that knowledge is power? Do you aspire to optimum health? Do you believe that an ounce of prevention is worth a pound of cure? If so, you may be vulnerable to reassurance seeking rituals. Information-Seeking vs. Reassurance Seeking Reassurance seeking rituals involve mentally preparing for potential threats. These compulsions are often based around behaviors such as asking questions or looking up information about disease prevention, transmission, incubation, or symptoms. Because reassurance seeking rituals are subtle, they might easily slip past you. You might be thinking, “These behaviors are not rituals. They’re simply responsible behaviors.” Fortunately, not all information-seeking is compulsive. When I worked at the St. Louis Behavioral Medicine Institute (SLBMI), Alec Pollard discussed the differences between information-seeking and reassurance seeking. Because information-seeking behaviors are used to become informed, they involve asking questions one time (only) to obtain needed information. Information-seekers understand the limits of knowledge and ask answerable questions, accept uncertain answers (when appropriate), and use information obtained to draw conclusions. Decisions tend to be quick and result in some type of behavior change or action. In contrast, reassurance seeking behaviors are attempts to reduce OCD doubt and uncertainty, as well as anxiety. As such, reassurance seekers often ask the same question multiple times in slightly different ways. Many sources are consulted, and often the same source is consulted multiple times to increase understanding and reduce potential miscommunication. Reassurance seekers often worry that they haven’t understood the answer properly, and they frequently ask for answer repetition or clarification. Reassurance seekers often ask unanswerable questions or questions that their conversation partners cannot (or are not qualified to) answer (e.g., “Do you think I’m going to get sick?” or in the case of scrupulosity, “Do you think I’m going to hell?”). They often know the answer they want to get in advance of asking the question and have a difficult time tolerating...
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OCD & Contamination: Washing & Cleaning Compulsions/Rituals

OCD: Common Compulsions In my last post about OCD, I discussed reasons why people do rituals. This time, I’ll identify specific rituals that are common in obsessive-compulsive disorder (OCD) characterized by a fear of germs, contamination, diseases, and other health-related ills. OCD: Hand-washing Rituals/Compulsions Hand-washing is a very common ritual and typically involves prolonged and frequent hand-washing behaviors. These washing behaviors may involve a particular sequence, order, or rhythm. Some individuals count while washing or wash in multiples of particular numbers. If these washes are interrupted, the individual may feel the need to repeat the entire sequence to make sure that the wash has been performed “properly.” Although people with OCD may think that their washing rituals are primarily for hygienic reasons, the true function of washing rituals is to reduce feelings of distress, anxiety, doubt, and vulnerability. The frequency and intensity of these washes and the use of abrasives or antibacterial soap often results in dry, reddened, or cracked skin. In some cases, washing causes bleeding, scarring, or other skin damage. Washing continues until the person feels less anxious about their particular OCD feared outcome. OCD: Showering Rituals/Compulsions Similarly, individuals with health-related OCD may take long, frequent showers. Showers are often taken using scalding hot water. If bathing, some individuals elect to literally boil their bath water in order to reach antiseptic temperatures. Showers may be taken routinely after certain events, such as after having a bowel movement. Others wash upon returning home in order to maintain a distinction between “clean zones” (the house) and “dirty zones” (the outside world). Like the hand-washing behaviors described above, showering often follows a particular sequence or order. Shower routines frequently develop around the idea of not cross-contaminating body parts. In addition to following a specific sequence, individuals may wash certain body parts multiple times (e.g., genitals). Others will entirely avoid direct contact with certain body parts for fear of contamination (e.g., genitals, feet, anus). After showering the individual may exhibit rituals that involve drying body parts in a particular order. Others will allow their bodies to “drip dry” or “air dry” so that their bath towels don’t “spread contamination.” Some individuals dry their bodies excessively using hair dryers in order to remove residual moisture that they fear may be hospitable to the growth of germs or bacteria. Obsessive-compulsive disorder (OCD) is a disease characterized by contradictions. Elaborate rituals may be used...
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OCD & Contamination: Reasons Why People Do Rituals/Compulsions

In my last post, I identified several idiosyncratic feared outcomes in OCD that are associated with contamination/health-related obsessive-compulsive disorder (OCD). Obsessions are intrusive, recurrent, and distressing thoughts, impulses, or images related to these feared outcomes. Today, I’ll discuss the function of compulsions. Why do people with OCD do rituals? Compulsions, or rituals, are the other main feature of OCD. These physical and/or mental behaviors reduce the anxiety brought on by obsessions and reflect one’s attempt to avoid, reduce, or prevent certain feared outcomes from occurring. Ask someone with a fear of contamination, disease, illness, or germs why they ritualize; and they will likely tell you that rituals serve as a means to destroy, neutralize, or escape from potential pathogens. As a consequence, rituals common to health-related OCD often incorporate washing, cleaning, disinfecting, and sanitizing behaviors. Continuous OCD doubt and uncertainty about whether or not one’s hands are sufficiently “clean” perpetuates these rituals. Although the obvious function of washing-related compulsions is to neutralize health-related threats, this is not the “true” reason why people wash. Washing actually serves the more subtle function of changing a feeling. Rituals are attempts to shift one’s mental state: to exchange feelings of threat for feelings of safety. Compulsive behaviors neutralize a perceived threat and reduce feelings of vulnerability to danger. They allow you to “escape” from unwanted feelings. In this context, the true function of washing becomes apparent: washing is the means by which individuals with OCD reduce unwanted fear and anxiety. In a sense, compulsions can be conceptualized as maladaptive coping skills. Unfortunately, adherence to rituals as a primary coping mechanism prevents the development of other, healthier coping skills. Compulsions also prevent the occurrence of corrective learning experiences that would otherwise disconfirm faulty OCD-related beliefs. Rituals Eventually Stop Working Another problem with rituals is that they provide only temporary relief and often their perceived effectiveness decreases with time. This causes the individual to perform longer or more elaborate rituals to achieve the same amount of anxiety reduction. It’s a bit like chasing a feeling that continually gets further and further out of reach. The more you reach for it, the more elusive it becomes. This is why, if left untreated, rituals tend to increase and become more time-consuming. Fortunately, exposure and response prevention can short-circuit the OCD cycle and reduce your symptoms. Join me next time when I describe common health-related OCD compulsions and...
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OCD & Contamination Fears: Feared Outcomes (Example: HIV/AIDS)

In my last post, I identified several types of obsessions that are associated with contamination/health-related obsessive-compulsive disorder (OCD). These include the fear of: Germs and getting sick. Making others sick. Developing an incurable illness in the future. Experiencing extreme and uncontrollable disgust or distress. Other unwanted negative outcomes related to the spread of germs, contaminants, or other agents. Given the idiosyncratic nature of obsessive-compulsive disorder (OCD), I thought it would be useful to talk a bit more about feared outcomes. Feared outcomes can be very different for different people, even when you’re dealing with the same surface obsession. Moreover, sometimes the immediate feared outcome (getting sick) differs from the ultimate feared outcome (dying from a disease). Consider the OCD fear of being infected with HIV. Individuals who experience this health-related OCD obsession often experience distress related to very different feared outcomes. OCD: Feared Outcomes Related to AIDS/HIV Obsessions Many are afraid of death and fear dying from AIDS. Others are afraid of pain and discomfort during the years preceding death. They may fear symptoms of the illness or even the side effects of treatment (e.g., nausea). Others fear that if they were to contract HIV that they would become severely depressed. It is the thought of a potentially chronic depression that is intolerable. Some worry that if they developed AIDS and experienced depression that they would have no option other than to commit suicide. The possibility of killing oneself then fuels moral, religious, or ethical distress. Thoughts of developing AIDS then begin to elicit automatic thoughts of a hopeless moral bind or even the possible threat of damnation (due to committing an “unpardonable sin”). Others worry that if they developed AIDS, they might die and leave behind loved ones (e.g., spouse, children) who might have a difficult time providing for themselves. Others worry that chronic illness will be a burden on their families. They fear potential guilt or the emotional or financial toll of chronic illness. Others fear the social stigma associated with AIDS and worry that when others learn of their illness, they might assume that they are promiscuous or homosexual. Others fear that if they die from AIDS, their lives would have been pointless or meaningless. It is the fear of a meaningless existence that makes the thought of contracting HIV so distressing. Some fear that if they do contract HIV, they might be responsible for unintentionally...
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Contamination & Health-related OCD: Obsessions, Fears, & Worries

What are common obsessions in contamination/disease/illness/health-focused OCD? OCD: Fear of Getting Sick Contamination- or health-related OCD is associated with persistent worries about one’s health or the health of loved ones. Common obsessions in contamination-related OCD include the fear of getting sick with a serious illness like rabies, ebola, H1N1 (swine flu), Creutzfeldt-Jakob disease, mad cow disease, hepatitis, or avian influenza. Other frequent obsessions focus on the fear of contracting sexually-transmitted diseases (STDs) such as AIDS/HIV, herpes, HPV, syphilis, or chlamydia. Chronic progressive diseases, like AIDS, that have no known cure tend to evoke extreme anxiety. Individuals with OCD fear both getting sick and the negative consequences associated with illness, which may range from pain and discomfort to serious repercussions such as death, sterility, or deformity. OCD: Fear of Making Others Sick Other individuals’ obsessions focus almost exclusively on potentially infecting other people. These individuals may be convinced that they are carriers for certain illnesses and may worry that they will spread disease to children, loved ones, or strangers. This type of OCD is common in parents (especially mothers) who are afraid of infecting their children. Because OCD is based on fear rather than logic, these worries tend to persist even if the individual is in perfect health. In other cases, individuals with OCD are actually disease carriers. These individuals often experience extreme guilt and fear over the possibility of infecting others with their illness. They tend to be very conscientious and possess a heightened sense of responsibility for guarding others’ health. This type of OCD is especially distressing in the context of chronic illnesses like STDs (herpes, HPV, AIDS), because the individual may feel guilt over having contracted the original illness. OCD: Fear of Getting Sick in the Future In still other cases, OCD health-related obsessions tend to focus more on negative health events that might occur at some future date. These fears include getting cancer, having a stroke, or developing Alzheimer’s disease. These events might occur relatively unpredictably or might involve exposure to present risk factors (e.g., smoking, exposure to asbestos/lead/mold, carcinogens, chemicals, or radiation). OCD: Fear of Disgusting Things & Situations Sometimes contamination-related OCD is triggered by exposure to “disgusting” things. Common triggers include oily and sticky substances, body fluids and bodily secretions, and animals. Feces, urine, sweat, saliva, blood, sexual fluids, and body hair can illicit a strong disgust reaction that may not be directly linked...
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OCD: Screaming, Blurting Out Obscenities/Cursing/Profanity, & Other Unwanted Impulses

Question: I’m a teenager and keep having OCD symptoms related to impulse control. I often worry that I’ll lose control and scream or blurt out obscenities. I am especially triggered in quiet public places like classrooms, churches, and movie theaters. I have never actually acted on my impulses and cursed in public, but I still feel very anxious whenever these thoughts occur. Do you have any tips for me? These types of symptoms are very similar to other OCD symptoms in which people worry about losing control and acting on unwanted impulses. Most typically, these types of thoughts attach to situations that are considered morally or socially taboo. Related OCD symptoms include fears about losing control and: Harming a loved one (most often a child, spouse, or parent). Killing a loved one (i.e., stabbing, shooting, suffocating, or poisoning). Killing or harming the self (i.e., suicide obsessions, fear of jumping from high places). Engaging in inappropriate sexual behavior (e.g., the urge to expose one’s genitals in public, undress in public, or touch another person’s genitals). Engaging in socially inappropriate behavior (e.g., cursing/using profanity/dirty words, insulting others, making negative comments, calling people names). Engaging in criminal behavior (e.g., theft/stealing, arson, vandalism, rape). Confessing non-committed criminal activity (e.g., talking about terrorism while at the airport/during security screenings, confessing crimes to police officers, mentioning guns/weapons while undergoing security screenings at courthouses or schools). For individuals with OCD, these thoughts and urges are distressing and are often a source of guilt and shame. Many individuals with OCD report that these urges are unwanted, but others get confused because they worry that the reason the thoughts keep occurring is because they secretly want to act on them. This is not the case. This phenomenon simply reflects the doubt and uncertainty that is characteristic of OCD. In your situation, I would recommend finding a CBT therapist to help you address your OCD in the right way. Check out the providers at www.ocfoundation.org. Treatment can be confusing, and you want to make sure that you’re selecting strategies that are going to move you in the right direction. Once you’ve found a specialist in OCD treatment, you might consider the following four strategies for addressing your obsessions and compulsions: OCD Treatment Tips for Unwanted Impulses/Urges 1. Practice non-avoidance of your OCD symptom triggers. The key is to embrace vulnerability and to intentionally put yourself in situations that trigger...
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OCD Triggers in Daily Life? Don’t Ritualize. Be Strategic! 3 Tips for Fighting OCD.

Question: I know about ERP, and I understand that OCD symptoms can be reduced by resisting rituals and then habituating to the anxiety brought on by obsessive thoughts. However…what if an obsessional thought requires no ritual? Confused! Great question. I think that in all cases of obsessive-compulsive disorder (OCD), there is some type of ongoing ritual that maintains the obsessional thought. This is because OCD is caused by threat misappraisals that are perpetuated and negatively reinforced by compulsive behaviors. As long as your compulsive behaviors remain in place, you are prevented from having the type of corrective learning experiences that are necessary for you to recover from your OCD. The reason that ERP is so effective is because it allows you to build these types of corrective learning experiences into your daily life. Sometimes a person has very obvious rituals; other times, rituals are more subtle. If you’re struggling with identifying your rituals, take a look at this list. With your example, the ritual might be mental rather than behavioral, which can make it more difficult to identify. I would ask yourself, “When my obsessive thought makes me feel anxious, what do I then do in order to escape/reduce this anxiety?” The answer is your ritual. This is the reason why trying not to think about an obsession can (for some people) become a mental ritual. Fortunately, there are multiple solutions to this problem: Strategies for Responding to Spontaneous OCD Triggers 1. Do a thought exposure (imaginal exposure) in which you sit with the thought and focus on it purposefully. If you allow enough time to do this, you will eventually habituate. Note: you may need to do this multiple times but the process of habituation should accelerate as you get more practice. Some people use recorded audio loops to hear the thought again and again; others write the thought over and over again; still others say it out loud. This is a good example of ERP (exposure + response prevention). 2. Allow the thought to be there and don’t try to squelch it…but continue to go on with your day while allowing the thought to be there. This is a good example of response prevention. Many people may also include an exposure element by elaborating on the thought, giving it more detail, taking it to extremes…with the express purpose being that of habituation to the thought. 3. Another...
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Exposure Therapy’s Most Common Mistake: All Eggs in the Habituation Basket

Many people have an incomplete understanding of exposure therapy… …be it exposure and response prevention (ERP) for OCD, intentional mistake practice for social anxiety, or interoceptive exposures for panic disorder… This is true for exposure newbies, seasoned exposure veterans, and even some good CBT therapists. This limited understanding is based on the following flawed logic: Premise 1: Anxiety disorders involve fear. Premise 2: Fear is reduced through habituation. Premise 3: Habituation is accomplished via exposure. Conclusion: Habituation is the process by which individuals recover from anxiety disorders. Note: This conclusion is only partially correct. Exposure, when done right, is about much more than just habituation. It’s about learning to see the world in a new way and developing a different type of relationship with your symptoms. Exposure can help you challenge unhealthy, false beliefs about yourself and the world; learn to take risks and make choices that are consistent with what you want out of life; develop confidence in your ability to overcome challenges; and learn to tell the difference between you (the person) and your symptoms. The next time you complete an exposure, ask yourself, “Why am I doing this exposure?” If your only answer is “To habituate,” you might need to re-evaluate what you’re doing in therapy. What have you learned from your exposures? How has your relationship with your symptoms changed as a consequence of challenging them? Please share below. …or continue the discussion on Facebook, Twitter, or...
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Sensorimotor OCD & Social Anxiety Differential Diagnosis: “Obsessive Swallowing”

Reader Question: For the past year, I have been dealing with OCD-related sensorimotor obsessions focused on swallowing. My symptoms started during a class discussion in which I noticed myself swallow. Since then, whenever I am in a lecture or quiet place surrounded by people, I become deeply focused on my own swallowing and worry that others will notice my swallowing and then judge me. I am practicing meditation and daily exposures in which I sit down in a quiet room and intentionally invite the swallowing in. I also purposefully invite the swallowing in throughout the day, even when I am in the presence of friends. I try to be mindful of my swallowing without doing anything to avoid it or mask it. Even though my awareness of swallowing has not entirely gone away, the anxiety associated with it has decreased significantly. However, I find myself feeling impatient and worried on the random days when my OCD-related anxiety flares up. For me, the most difficult situations continue to be one-on-one conversations, especially when I notice other people swallowing after I do. This makes me worry that I am spreading the condition, even though I know rationally that this is not possible. Do you have any recommendations for how to deal with OCD-related swallowing obsessions when they are triggered by interactions with friends? Should I seek professional help to address my sensorimotor obsessions and compulsions? I have always felt like a very confident and outgoing person, but this frustrating obsession has kept me from being my normal self. Your general approach of allowing yourself to focus on the swallowing is sound as long as you are not doing anything to intentionally change the behavior (i.e., trying to swallow with less force or with less sound) or “perfect” the behavior. However… Based on your description, it is likely that you are experiencing significant symptoms of social anxiety in addition to OCD-related symptoms. It is also possible that your symptoms might be primarily social in nature, rather than being OCD-based. This important differential diagnosis issue should guide treatment selection. Social Anxiety vs. Sensorimotor OCD Obsessions/Compulsions: Treatment Implications Unfortunately, meditation and imaginal exposure will not address the social aspects you’ve described. You must specifically target these social situations directly in order to habituate to your fear. Your in vivo exposures should address the mistaken belief that swallowing loudly will lead to a negative outcome...
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Palm Beach (South Florida) OCD Support Groups: Adults, Kids, Teens

Attention all residents of Palm Beach Gardens, Jupiter, Juno, West Palm Beach, Boca Raton, Boynton Beach, Lake Worth, Royal Palm Beach, Wellington, Delray Beach, Pompano Beach, Fort Pierce, Port St. Lucie, Greenacres, Miami, and Fort Lauderdale. We am pleased to announce that the Center for Psychological & Behavioral Science is now sponsoring free monthly support groups for Palm Beach County kids, teens, and adults with OCD!  All groups are led by licensed psychologist Dr. Steven Seay and meet in our office in Palm Beach Gardens, FL. The monthly OCD support group schedule is as follows: OCD Support Group for Kids & Teens (17 & younger) – Led by Dr. Seay Meets Monthly (specific times/dates vary based on attendee availability) Location – Our Office (address below). If you would like to help choose our next meeting date or get announcements about upcoming meeting times, you can access our sign-up form here. Upcoming meeting dates/times will also be listed on our events calendar. OCD Support Group for Adults (18 & up) – Led by Dr. Seay Second Tuesday of the Month @ 6:30pm Location – Our Office (address below). If you would like to get announcements about upcoming meeting times, you can access our sign-up form here. Upcoming meeting dates/times will also be listed on our events calendar. Member Led OCD Support Group for Adults (18 & up) – Dr. Seay not in attendance (Adult family members of people with OCD also welcome to attend) Meets Monthly (specific times/dates vary but usually on the 4th Thursday of the Month @ 6:30pm) Location – Palm Beach Gardens Library (11303 Campus Drive Palm Beach Gardens, FL 33410). If you would like to get announcements about upcoming meeting times, you can access our sign-up form here. Upcoming meeting dates/times will also be listed on our events calendar. Our address is: Center for Psychological & Behavioral Science 11641 Kew Gardens Avenue, Suite 207 Palm Beach Gardens, Florida 33410 Phone: (561) 444-8040 (If you arrive late, please call so that we can let you into the building.) If you have OCD, please consider joining us and helping support others who are fighting the good fight against OCD. Questions? Comments? Sound off below. …or continue the discussion on Facebook, Twitter, or...
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Treatment for Body-Focused Obsessions & Compulsions in OCD (e.g., Swallowing, Breathing, Blinking)

This post is the last in a series of posts discussing body-focused obsessions and compulsions (aka, sensorimotor, somatosensory, or somatic obsessions and compulsions) in obsessive-compulsive disorder (OCD). This series was inspired by an original article written by Dr. David Keuler for OCDchicago.org. You can access Dr. Keuler’s excellent article here. Ruling out Medical Causes for Body-Focused Obsessions & Compulsions in OCD (sometimes called Sensorimotor or Somatic Obsessions) Before we begin discussing cognitive behavioral treatment for body-focused obsessions and compulsions, it is important to note that there are many non-psychological causes of physiological symptoms. Consequently, it is essential to be evaluated thoroughly by a medical doctor in order to rule out any possible physiological causes for your symptoms. If a medical disease is responsible for your issues with swallowing, breathing, blinking, or moving, the techniques I will be discussing below are inappropriate and may prevent you from getting the medical help you need. There are a variety of serious neurological conditions that can cause these types of symptoms, and it’s important that you rule these out prior to seeking a psychotherapy-based solution. In some cases, specialty medical providers might also be consulted to rule out health-related problems. For example, in the case of swallowing issues, it might be useful to consult with a physician who specializes in ENT (ear, nose, and throat) issues, a gastroenterologist, or a neurologist. Confirming an OCD Diagnosis Assuming that your healthcare providers have ruled out medical causes for your symptoms, you should establish a relationship with a psychologist to make sure that your symptoms fit the diagnostic profile for OCD. A trained anxiety specialist can help you differentiate between specific phobias, panic, obsessive-compulsive disorder (OCD), and other anxiety-related conditions. In comparison to some of these other conditions, OCD is more likely to be associated with generalized and pervasive fears, fears that span multiple domains, fears that jump from domain to domain over time, and (in the case of body-focused OCD) the specific fear of being unable to redirect your attention away from physiological processes. Moreover, in almost all cases, OCD will be associated with both obsessions (e.g., intrusive thoughts, impulses, or images) and compulsions (attempts to reduce the anxiety associated with your obsessions). A simple way to distinguish an obsession from a compulsion is by asking yourself the following two questions: What increases my anxiety? (These are your obsessions.) What do I do to try...
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OCD Core Fears Related to Body-Focused Obsessions & Compulsions (e.g., Swallowing, Breathing, Blinking)

This post is the second in a series of posts discussing body-focused obsessions and compulsions (aka, sensorimotor, somatosensory, or somatic obsessions and compulsions) in obsessive-compulsive disorder (OCD). This series was inspired by an original article written by Dr. David Keuler for OCDchicago.org. You can access Dr. Keuler’s excellent article here. OCD Core Fears Related to Body-Focused Obsessions (also called Sensorimotor or Somatic Obsessions) In Part 1 of this series of posts, I discussed the basic characteristics of body-focused (also termed sensorimotor [Keuler, 2011], somatosensory, or somatic) OCD. This type of OCD is extremely distressing and is associated with hyperawareness of particular bodily processes, urges, or sensations. Obsessions and compulsions often focus on breathing, swallowing, tongue movements, blinking, or other bodily phenomena (Keuler, 2011). In clinical terminology, obsessive-compulsive disorder is a heterogeneous disorder. This means that different people have different combinations of OCD symptoms. Despite this variability, many individuals with body-focused, sensorimotor OCD share common fears related to their symptoms. OCD worry about having the symptoms last forever (Keuler, 2011). What if my symptoms never go away, and I have to live the rest of my life like this? What if life is never satisfying again? What if I can never engage in [insert specific activity] without thinking about this? (Common examples include sleeping, eating, speaking, reading, or writing.) What if I lose my job (or fail out of school) because of this? What if I can never focus again? What if I can never sleep again? What if my mind is never “at peace” again? OCD worry about the underlying cause of the symptoms. Why am I having these symptoms? There must be something seriously wrong with me. What if I have a brain tumor that is causing these symptoms? What if I have schizophrenia or another type of severe mental illness? What if I have brain damage in the parts of my brain that control these processes (e.g., the medulla oblongata or cerebellum)? OCD worry about specific feared outcomes. What if I choke and die because I didn’t chew my food enough? What if my heart stops beating? What if my heart is beating at the wrong rate? What if there’s something wrong with my heart? What if I stop breathing? What if I’m breathing at the wrong rate? What if there’s something wrong with my lungs? What if I’m damaging my eye muscles because I’m blinking too...
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Body-Focused Sensorimotor Obsessions & Compulsions in OCD (Swallowing, Breathing)

This post is the first in a series of posts discussing body-focused obsessions and compulsions (i.e., sensorimotor obsessions and compulsions) in obsessive-compulsive disorder (OCD). This series was inspired by an original article written by Dr. David Keuler for OCDchicago.org. You can access Dr. Keuler’s excellent article here. Body-Focused Obsessions and Compulsions in OCD (sometimes called Sensorimotor, Somatosensory, or Somatic Obsessions/Compulsions) As I have mentioned previously, one particularly distressing symptom of obsessive-compulsive disorder (OCD) can be hyperawareness of particular bodily sensations. Body-focused obsessions (also called sensorimotor obsessions (Keuler, 2011) or somatosensory obsessions) often feel intolerable and typically involve getting your attention “stuck” on thinking about or analyzing particular autonomic processes. Thoughts may become fixated on one’s breathing rate, heart rate, swallowing, blinking, eye “floaters”, or flickering of the visual field (Keuler, 2011). Sufferers frequently label the problem as conscious breathing/conscious swallowing/conscious blinking, obsessive breathing/obsessive swallowing/obsessive blinking, or compulsive breathing/compulsive swallowing/compulsive blinking. Although for most individuals these processes occur automatically below conscious awareness, individuals with this form of OCD find themselves acutely and frustratingly aware of their own bodily sensations. People with these obsessive-compulsive symptoms attend to how often and how “completely” these processes have occurred. For example, individuals with respiration/breathing-related symptoms often try to consciously control their breathing rates, as well as how “fully” each breath is inhaled and exhaled. Obsessions and compulsions involving breathing, swallowing, and blinking are quite common in this form of OCD. However, other individuals may over-attend to fullness and other sensations in the bladder, stomach, or digestive system. Still others find their attention gets overly focused on the urge to burp or belch. Another different, distressing symptom involves analyzing the amount and frequency of eye contact with other people (Keuler, 2011). Doubt and uncertainty about how often and how intensely to make eye contact can lead to avoidance of other people, which may disrupt performance in work, school, and social settings. Additional examples of body-focused obsessions and compulsions include paying excess attention to how your tongue moves when eating or speaking, the timing of your speech, the amount of saliva in your mouth, the sound you hear when swallowing or chewing, how your teeth feel when your mouth is closed, or how your skin feels as it brushes against your clothing. Although compulsions associated with these symptoms often involve consciously controlling these processes, mental rituals occur as well. These include repeating certain words or phrases...
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OCD Treatment (ERP & CBT): Exposure & Cognitive Restructuring

Question: To what extent would a change of mindset (e.g., changing my expectations for myself) be helpful in recovering from OCD? What is likely to happen if I delay formal treatment with a psychologist and work instead on changing my own mindset? OCD Treatment Components: Cognitive Restructuring + Exposures Regardless of whether or not it occurs in the context of formal psychotherapy, changing your mindset will be a critical component of your recovery. If you do any reading on cognitive behavioral therapy (CBT), you’ll see this referred to as “cognitive restructuring.” Devoting time to challenging and modifying your underlying belief system is essential for fighting OCD, but research on OCD indicates that this process alone will probably be insufficient if it’s not integrated with appropriate exposure-based behavioral strategies (e.g., exposure and response prevention [ERP]). OCD Treatment Delays In general, I do not advocate treatment delays. As you get older, OCD tends to become more intractable and intertwined with who you are, making it more difficult to separate yourself from your OCD. Moreover, most people find that their rituals morph and expand over time, if left untreated. Nevertheless, everyone is different with their own unique biology and experience. There is certainly no guarantee that in your particular case, your OCD will get worse over time. However, the prevailing view is that earlier treatment is more effective and staves off later problems. This is why I recommend early treatment for kids, teens, and adolescents with cases of early onset (pediatric) OCD. OCD Professional Treatment vs. Self-Help Strategies The best thing you can do for yourself is to combine cognitive techniques (e.g., cognitive restructuring) with the behavioral components of exposure and response prevention (ERP). The basic principles of treatment will be the same whether you are tackling symptoms related to checking, potential danger/disaster, harm, repeating, washing/contamination, or another type of compulsive behavior. There are some good self-help books available to provide general guidance, but these resources typically are not a good substitute for individual therapy conducted by a trained psychologist. You will be most likely to progress quickly if you have an OCD specialist physically present to educate and guide you through early exposures. For tips on completing ERP exposures, please refer to my earlier post on identifying and resisting subtle rituals, which will help you maximize your treatment gains. Questions? Comments? Tips for challenging OCD-related cognitions? Share below. …or continue the...
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OCD Treatment: OCD vs. Me. How do I Tell the Difference?

Question: Because many of my OCD rituals are related to my professional identity, I’m worried that changing my rituals will somehow change those parts of me that I like (e.g., my personal goals and ambitions). Should I be concerned about this? Early Onset OCD in Kids & Teens (Pediatric OCD) Many people worry that by fighting their OCD, they will lose essential parts of themselves. This is particularly true for adults with obsessive compulsive disorder, who have had to deal with OCD for most of their lives. Because OCD often begins early in childhood and can have a chronic course, it can be difficult to separate yourself from your OCD symptoms. In many pediatric OCD cases, kids with OCD exhibit symptoms by age 10. Shockingly, in certain cases, even toddlers can show clinical signs of obsessive-compulsive disorder. There are some documented cases of 2-year-olds demonstrating early onset symptoms, which certainly underscores the genetic underpinnings of the illness. In early onset cases, symptoms tend to worsen when the child begins going through puberty. Not everyone develops OCD as children, however. Other individuals don’t exhibit significant obsessive compulsive symptoms until later in life (e.g., late teens/early adulthood). Regardless of the age of onset for OCD, the average amount of time between symptom emergence and treatment is greater than 10 years. During this intervening period, individuals with OCD often lose sight of who they are and find it difficult to separate themselves from their OCD symptoms. Where does the individual end and OCD begin? This is particularly true in cases involving perfectionism, scrupulosity, Pure-O symptoms, harm and/or sexual obsessions, and hoarding, in which symptoms tend to intermingle with personality traits, guilt, and shame. OCD Compulsions Reflect Symptoms, Not You The reality is that rituals do not make you who you are. You are a person first and foremost, and your drives, desires, and ambitions are uniquely yours. I conceptualize rituals as symptoms of an illness. They don’t make you who you are; they’ve simply been a maladaptive coping strategy you’ve used to manage your anxiety. Ultimately, this strategy has proven to be more detrimental than helpful. If anything, your symptoms tend to hide who you actually are. OCD is greedy, and it likes nothing more than to wreak havoc on your confidence, sense of humor, and interpersonal relationships. Oftentimes, when individuals with OCD commit to treatment, they rediscover positive aspects of themselves...
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Pure-O OCD Rituals: Starting Over, Resetting, & Undoing

Question: It’s hard to describe this, but I feel like every few days I need to mentally “start over” by doing a variety of mental and behavioral rituals. I don’t want to live like this, but I’m afraid that if I undergo treatment and stop my OCD rituals, I won’t be the same person with the same drives. Starting Over, Resetting, & Undoing Compulsions in OCD First, please rest assured that you’re not alone in experiencing these symptoms. Many people with OCD (“Pure-O” or otherwise) refer to them as “starting over” compulsions, “resetting” compulsions, or “undoing” compulsions, which serve the function of returning to a clean mental slate. Sometimes these compulsions consist of particular movements, self-statements, mental activities, or complex rituals with both behavioral and mental components. They are not as common as other types of rituals (e.g., washing, re-arranging), but they’re more common than you might think, particularly in Pure-O OCD. Many people resist talking about them, because they fear that other people might not understand. Other rituals associated with Pure-O OCD are described here. There are two other terms that might describe some of what you are experiencing: emotional contamination (also referred to as mental contamination) and scrupulosity. Emotional Contamination (“Mental Contamination”) in OCD Emotional contamination refers to the fear of being changed by direct or indirect contact with certain types of people, ideas, or situations. Emotional contamination might be the case if you feel more triggered when exposed to others who are less achievement-oriented than yourself. If you google emotional contamination, many of the stories you’ll find probably won’t perfectly describe your exact symptoms. However, the reason I mention it is because it sounds like your drive to be productive and live up to your potential sometimes gets thwarted by your own humanity (e.g., fatigue, inattention). Your rituals are then the process you use to reduce the resultant anxiety you feel when you can’t live up to your own high expectations. In a way, it might be a form of purging/neutralizing emotional contamination. Scrupulosity in OCD Scrupulosity also incorporates many of the moral elements of what you’re describing. In particular, I think the moral imperative you feel to live up to your potential, to maximize the usefulness of things, to avoid waste, to be a responsible person, and to avoid mistakes has a scrupulous quality. Please note that scrupulosity can be either religion- or morally-based. Many...
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OCD & D-cycloserine: A Promising Medication for OCD Treatment

As someone who has long been enamored with basic science, I find it fascinating when classic medications are re-purposed in surprising ways.  One of the newest examples of this is the use of D-cycloserine (also known as Seromycin) in the treatment of obsessive-compulsive disorder (OCD). What’s interesting about D-cycloserine is not so much what it is…but what it isn’t: D-cycloserine is neither an SRRI nor any other type of antidepressant (e.g., Prozac). It’s not an anti-anxiety medication (e.g., Xanax, Klonopin). It’s not even an atypical antipsychotic (e.g., Abilify, Risperdal). If it’s not one of the above, then what is it? The answer might surprise you.  Seromycin is actually an antibiotic that was originally developed to help fight off tuberculosis.  What’s exciting about using an antibiotic to treat OCD is that it’s not subject to the same side effects as other medications (i.e., the SSRIs, anxiolytics, or antipsychotics).  In fact, most clinical studies have found few, if any, significant side effects when using D-cycloserine in OCD treatment. Before I go further, there’s an important caveat to keep in mind: Research on D-cycloserine in OCD treatment is still a work-in-progress, so it’s important to maintain some healthy skepticism on this issue. Research studies looking at using D-cycloserine to treat OCD have been fairly limited, and the results of these studies have been mixed.  Some studies have suggested that the medication has small or non-significant effects, whereas other studies have found the medication to be beneficial.  Several recent, placebo-controlled studies have been quite promising and have indicated that taking seromycin can initially “speed up” the therapeutic response to exposure and response prevention therapy (ERP), a form of cognitive behavioral therapy (CBT) developed to treat OCD.  In essence, you benefit more from initial ERP therapy sessions.  D-cycloserine doesn’t appear to have any effects on OCD when taken on its own (i.e., when not combined with exposure and response prevention).  For more information regarding how ERP is thought to work, visit my blog post here. It’s important to note that D-cycloserine doesn’t appear to offer any long-term benefits above and beyond what you would get from ERP alone.  In the end, you’re likely to achieve the same amount of symptomatic improvement whether or not you take the medication.  However, the research indicates that you’re likely to get more “bang for your buck” if you’re taking Seromycin during early exposure sessions.  This is important, because it reduces early treatment frustration and drop out. How does D-cycloserine work?  Does the fact...
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“Pure-O” OCD: Common Obsessions & Mental Rituals

As a follow-up to my previous post on Pure-O OCD, I thought it might be helpful to identify some obsessions that are commonly reported by individuals with Pure Obsessional OCD.  These same obsessions may also be experienced by individuals with non-Pure-O forms of the disorder.  Keep in mind that some of these symptoms are quite common (when experienced in a limited form) and may or may not represent an underlying psychological condition.  If you experience symptoms like these, consult with your doctor for clarification.  I am also available to conduct assessments and provide treatment if you’re located in South Florida (Palm Beach Gardens, Jupiter, West Palm Beach, Fort Lauderdale, Boca Raton, Boynton Beach, & Miami). Remember that most people who have Pure-O OCD actually perform compulsions.  These compulsions just tend to be mental rather than behavioral in nature.  Mental rituals are varied and include such activities as repeating certain words or phrases in one’s head, counting, intentionally thinking “positive thoughts” to counteract “negative thoughts”, pre-planning words before speaking, making mental lists of similarities between one’s own experience and others’ experiences, conducting online research to prove or disprove a fear, or repeating/restarting prayers due to distraction or worry that one’s prayers are not 100% genuine. For some individuals, mental rituals also include complex cognitions.  Complex mental rituals often begin simply with one of the following statements or questions and then take on a life of their own: OCD Mental Rituals “I would never do that…but what if I do?…I don’t want to…but what if I secretly do?” “Why is this happening?” “When will this stop?” “I can’t live this way…” “I need to know…” “I’ll never be strong enough to face this…” “I wouldn’t be having these thoughts if I didn’t secretly want this…” “Maybe I need to act on these thoughts to finally be rid of them and feel closure…” “It’s always going to be this way…” “I can’t take the chance, because if I did…” “If I could just figure this out, I would be able to move past it and it wouldn’t bother me anymore…” Such thoughts usually begin innocently enough, but in the case of mental rituals, they become repetitive, desperate, and counterproductive. The reason these thoughts are so seductive is because they have the semblance of being helpful.  People often feel that by engaging with these thoughts, they are somehow making progress in solving their own...
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Pure-O OCD (Pure Obsessional OCD): Hidden Rituals

“Pure-O” OCD, or Pure Obsessional OCD, is a relatively less common form of OCD that seemingly differs from classic presentations of the illness.  What distinguishes Pure Obsessional OCD from classic OCD is that in Pure-O OCD, symptoms are predominantly obsessive (rather than compulsive) in nature.  Although individuals with Pure-O OCD frequently experience intense and distressing obsessions, they typically report few (if any) overt compulsive behaviors.  However, in almost all cases, pure obsessionals do engage in a variety of rituals.  These rituals  just manifest as mental compulsions rather than behavioral compulsions. Unfortunately, most psychologists haven’t been trained in how to ask the types of questions that are necessary to identify these “hidden rituals.”  As a consequence, these rituals often go undetected.  Because effective treatment requires consistent response prevention, a failure to recognize and resist mental rituals makes true exposure and response prevention (ERP) impossible.  Treatment then proceeds in an ineffective and haphazard way, with neither the patient nor the therapist any the wiser. Not surprisingly, treatment for Pure-O OCD often fails.  However, treatment failure occurs not because the patient is an ERP non-responder, but rather because the most important part of treatment (i.e., response prevention) was unknowingly omitted.  Sadly, many individuals with OCD wrongly get labeled as being treatment refractory (treatment resistant), even though they have never undergone a single course of response prevention that appropriately targets their very real compulsions. Remember, not every ritual consists of an observable behavior.  Learn to more effectively fight your OCD and become a mental ritual detective by considering a few of the following “hidden” rituals that I assess when treating individuals in my South Florida (Palm Beach, Fort Lauderdale, Boca Raton, Boynton Beach, & Miami) psychological practice: Say No to Pure-O Common Mental Rituals Trying to “figure out” why you’re having a certain thought. Trying to counteract, or balance out, negative thoughts with positive thoughts. Trying to forcefully control an obsessive thought. Trying to “figure out” what type of person you are (e.g., questioning your own morality). Avoiding certain situations, people, or activities so that you don’t have an obsession. Reassuring yourself (e.g., telling yourself, “I’d never do that.”). Postponing certain behaviors or thoughts until “the right time” or until “they feel right.” Repeating thoughts, phrases, or words in your head. Repeatedly praying or asking for forgiveness (in a way that is not typical for others who share your faith). Questions? Comments? Sound off below. …or continue the discussion on Facebook,...
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Exposure & Response Prevention (ERP) for OCD: Treatment Mechanism

Question: How does ERP work?  What mechanism underlies it? Obsessive-compulsive disorder (OCD) is characterized by obsessions and compulsions.  Obsessions are disturbing thoughts, images, or impulses that increase feelings of anxiety. Compulsions (also known as “rituals”) are the strategies that individuals with OCD use to reduce the anxiety associated with obsessions.  Rituals are effective coping strategies in the short-term, in that they lead to fairly rapid decreases in anxiety.  However, rituals are considered maladaptive, because the anxiety relief they bring is short-lived.  Engaging in rituals ultimately increases the likelihood that obsessions will be re-experienced in the future.  This can be thought of as a positive feedback loop, in which compulsive behavior indirectly reinforces obsessions.  This is depicted in the bottom half of the included figure. The treatment of choice for OCD is exposure and response prevention (ERP), which not surprisingly, has two main components: 1) exposure, and 2) response prevention.  Response prevention refers to purposefully inhibiting one’s rituals, whereas exposure refers to willingly entering situations that are likely to trigger obsessions.  Both exposure and response prevention elements are necessary for making meaningful treatment gains. Response prevention is the critical component in “short-circuiting” the positive feedback loop in OCD.  When one implements regular response prevention, obsessions are no longer reinforced and ultimately decrease in frequency and intensity.  This is represented in the upper half of the included figure.  Purposeful exposure provides further opportunities to break this cycle.  The more exposures you complete, the more the positive feedback loop degrades.  Eventually, with enough practice, you will become immunized to many of your triggers. Some people get very stressed out at the prospect of completing exposures.  They think, “How could I possibly do an exposure? I’m anxious enough as it is!”  This sentiment is most common prior to initiating treatment and quickly fades once the individual begins practicing regular exposure.  If you feel this way, keep in mind that if you complete structured exposure according to a hierarchy of feared situations (e.g., using subjective units of distress [SUDs] ratings), the process is less likely to feel stressful and overwhelming. Questions? Comments? Sound off below. …or continue the discussion on Facebook, Twitter, or...
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Obsessive-Compulsive Disorder (OCD) – Decision Making Abnormalities

Does OCD affect decision making processes? Now that we have reviewed the neurobiological and cognitive abnormalities associated with OCD, what relevance might this have for predicting abnormalities on tasks of decision making?  Sachdev and Malhi (2005) recently have drawn attention to the substantial overlap between the circuitry implicated in OCD and the circuitry required for intact performance on simple decision tasks.  They suggest that due to the commonalities of these neural systems, individuals with OCD would be expected to exhibit deficits on tasks of decision making.  Furthermore, they indicate that OCD might even be conceptualized appropriately as a disorder of decision making, given that many of the hallmark features of the disorder seemingly arise from a primary deficit in decision making processes.  For example, the inability to decide whether or not one’s hands have been washed sufficiently might reflect a general problem with processing decision-relevant information (i.e., recognizing the information value of a handwashing behavior).  Their theory focuses largely on dysfunction within prefrontal cortex and other closely interconnected regions. As noted previously, the PFC includes the dorsolateral prefrontal cortex (DLPFC), the orbitofrontal cortex (OFC) and the anterior cingulate cortex (ACC).  The DLPFC is thought to facilitate decision making by processing and evaluating multiple environmental stimuli with the aid of working memory (D’Esposito et al., 1995; Prabhakaran, Narayanan, Zhao, & Gabrieli, 2000).  The OFC has been implicated in the processing of affective information (particularly reward-related information) from limbic areas that subsequently is conveyed to the DLPFC as a positive or negative bias (Sachdev & Malhi, 2005).  Affective and environmental stimuli then are integrated in the DLPFC in order to aid in action selection.  During tasks that are associated with limited affective cues, the OFC likely conveys little bias to the DLPFC; however, during tasks that require more complex emotional processing, the affective bias conferred by the OFC might more critically affect action selection.  In threatening situations characterized by marked emotional arousal, the OFC bias might be involved in selecting behaviors instrumental for guaranteeing survival.  Sachdev and Malhi (2005) have suggested that activity in the OFC might contribute to “gut-feelings” that are experienced in particular situations.  In disorders such as OCD that are associated with OFC hyperactivity, such gut feeling states presumably would be potentiated in emotionally intense situations and would increase the likelihood of selecting actions that minimize harm and promote survival. As described earlier, OCD also is associated with...
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Obsessive-Compulsive Disorder (OCD) – Cognitive Deficits

What cognitive deficits are associated with OCD? Cognitive abnormalities associated with OCD have been documented within the domains of basic learning processes, attention, and executive functioning, each of which arguably is requisite for intact decision making.  We will begin by highlighting abnormalities in basic associative learning processes that have been observed in OCD and subsequently will extend our discussion to higher level cognitive processes. Basic associative learning. The idea that pathological anxiety might develop initially via basic associative learning mechanisms was advanced largely by Mowrer (1939), who proposed a two factor theory about anxiety development.  Mowrer (1939) hypothesized that during an initial learning stage, anxiety develops via classical conditioning processes.  This occurs when a neutral cue becomes associated with fear due to a negative event.  Subsequent re-exposure to this previously neutral cue reactivates the somatic state of anxiety.  During a second stage of learning, the newly acquired anxiety is maintained and facilitated through operant reinforcement, such that the fear and anxiety aroused by exposure to the anxiety-eliciting cue is reduced by engaging in negatively reinforcing, stereotyped behaviors.  The anxiety reduction obtained by engaging in these responses is rewarding which increases the likelihood that these operant responses will be repeated in the future.  These stereotyped behaviors often are performed automatically and never are subjected to a reality test; thus, the individual never realizes that engaging in these behaviors is unnecessary. Tracy, Ghose, Stecher, McFall, and Steinmetz (1999) have suggested that individuals who later develop OCD might be biologically-predisposed to form associations rapidly between neutral environmental stimuli and anxiety.  Furthermore, these same individuals might learn quickly that engaging in compulsive behaviors can reduce this conditioned anxiety.  Thus, an enhancement of basic associative learning processes might mediate the development and maintenance of OCD.  This theory seems intuitively plausible; however, until recently, it had received little empirical attention.  Converging lines of evidence now support this learning-based behavioral conceptualization of OCD. Tracy et al. (1999) showed that individuals reporting elevated OCD-like characteristics acquired conditioned eyeblink responses to auditory stimuli predicting corneal air puffs more quickly than controls on a simple classical conditioning task.  Interestingly, enhanced classical conditioning was observed only on tasks completed under low attentional load.  Using an auditory discrimination conditioning paradigm, Mortimer (2002) subsequently found that OCD-like individuals exhibited a significantly higher percentage of conditioned responses to reinforced stimuli (CS+) over training blocks compared to healthy controls.  In contrast, Seay, McFall, and...
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Obsessive-Compulsive Disorder (OCD) – Neurobiology

What causes OCD? Researchers have had much recent success in elucidating the neural circuitry involved in OCD.  Advances in functional neuroimaging have identified robust alterations in neural activity within particular functional circuits in individuals with the disorder (Graybiel & Rauch, 2000).  Specifically, OCD is associated with pervasive disruptions in frontal subcortical circuitry (Luxenberg et al., 1988; Robinson et al., 1995).  Before we discuss abnormalities in this circuitry related to OCD, it is worth reviewing the generalities of this neural system. Frontal subcortical circuitry. According to Tekin and Cummings (2002), frontal subcortical circuits share several commonalities.  They often “originate in prefrontal cortex, project to the striatum (caudate, putamen, ventral striatum), connect to the globus pallidus and substantia nigra and from there connect to the thalamus.  There is a final link back to the frontal cortex [such that] each circuit forms a closed loop” .  The prefrontal cortex (PFC) can be subdivided into several regions including the dorsolateral prefrontal cortex (DLPFC), the orbitofrontal cortex (OFC) and the anterior cingulate cortex (ACC); and these subregions are involved in separate circuits (the DLPF circuit, the OF circuit, and the AC circuit, respectively).  These circuits have been implicated in various functional tasks.  Individuals with dysfunction in DLPFC areas often exhibit deficits in attention, reasoning, and mental flexibility.  Damage to OFC has been associated with personality changes including behavioral disinhibition and impaired judgment (Tekin & Cummings, 2002).  Work by Damasio and colleagues (1996; 1990) indicates that insults to OFC result in deficits in reward expectancies and preferences.  The ACC is closely interconnected with the limbic system and is thought to support motivation and affective behavior.  Due to its association with motor cortex, the ACC presumably mediates emotionally-motivated movement.  Together, the ACC and OFC influence the emotional value of stimuli and the selection of behavior based on possible reward. Saxena and Rauch (2000) have suggested that excess positive feedback within frontal subcortical circuits might drive the repetitive symptoms that characterize OCD.  What evidence supports this theory?  In individuals with OCD, resting hyperactivity within frontal subcortical loops has been observed reliably, and this activity is potentiated by symptom provocation (Saxena, Brody, Schwartz, & Baxter, 1998).  Interestingly, following either successful behavioral or pharmacologic treatment for the disorder, this hyperactivity diminishes to normal levels.  Empirical evidence implicating frontal subcortical circuitry in the etiology of OCD also includes work by Kelly (1980) who showed that lesions of the cingulate gyrus...
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Obsessive-Compulsive Disorder (OCD) – Overview

What is OCD? Obsessive-compulsive disorder (OCD) is a debilitating mental illness that affects nearly 2.5% of the population (American Psychiatric Association, 2000).  The primary features of the disorder include obsessions, which are recurrent and persistent thoughts, impulses, or images that cause severe anxiety and distress; and compulsions, repetitive behaviors or mental acts performed in response to an obsession.  Compulsions frequently are performed to reduce distress or prevent a dreaded event or situation from occurring.  Because individuals with OCD often spend many hours each day experiencing obsessive-compulsive symptomatology, the disorder severely impairs functioning across a variety of domains. According to Rasmussen (2005), individuals with OCD tend to adhere to highly rigid and disciplined notions about how to do things properly, “sacrificing opportunities for positive, pleasurable activities to maintain a position of disciplined appropriateness” .  Consistent with this view, cognitive rigidity has been proposed as a hallmark feature of the disorder.  Even in the absence of clinical OCD, individuals who exhibit a high degree of obsessive-compulsive characteristics also have been shown to be cognitively and behaviorally rigid (e.g., Cabedo, Belloch, Morillo, Jiménez, & Carrió, 2004; Mythili & Devi, 1982; Zohar, LaBuda, & Moschel-Ravid, 1995).  In an early description of OCD, Lion (1942) described a group of individuals diagnosed with “anancastic depression[1]” as being “indecisive, scrupulous, markedly superstitious…paralyzingly meticulous, and inclined to have morbid doubts” .  Current conceptualizations of OCD overlap with these early descriptions of the disorder and emphasize an association between OCD and inflated perfectionism, intolerance for uncertainty, and rigidity (e.g., Cabedo et al., 2004; Schultz & Searleman, 2002; Shapiro, 2001). How do these features present clinically?  Consider the case of a man with OCD who has recurrent obsessive thoughts that he has struck a pedestrian with his car while driving.  Although he has no actual recollection of hitting anyone, he nevertheless experiences persistent doubt related to whether he might have injured someone inadvertently.  These thoughts increase in intensity until the man retraces his driving route and checks the road for injured pedestrians.  Although the act of retracing and checking his route partially effects a reduction in anxiety, further doubt is aroused by the potential for having injured someone during the subsequent check and/or having overlooked evidence of an injured party during the check.  This scenario might replay itself numerous times over the course of a single commute, each time culminating in the man retracing his route to check for...
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OCD perfectionism & social anxiety treatment: Tweet your way to greater health

Looking for ways to overcome social anxiety or OCD-related perfectionism?  At the end of this post, you’ll find some strategies I use to help individuals in South Florida (Palm Beach, Fort Lauderdale, Boca Raton, Boynton Beach, & Miami) overcome their anxiety.  These exercises are examples of “Intentional Mistake Practice”, a CBT-based technique that can be used to challenge some of the problematic perfectionistic beliefs that are central to social anxiety and OCD. First, though, what do social anxiety and OCD-related perfectionism have in common?  Although on the surface, these anxiety disorders are quite different, individuals with social phobia and OCD often share many perfectionistic beliefs about the world.  Social anxiety (or “social phobia”) is characterized by excessive worry about being perceived negatively by others.  Individuals with social phobia often have perfectionistic expectations about their own behavior and question their social competence.  They fear potential shame, embarrassment, or rejection in social settings. In OCD, perfectionistic cognitions may also involve “performing” in front of others but more often involve personal perfectionistic standards.  These individuals often feel a moral imperative to live up to their true potential.  They often seek to give nothing but their best (100% of the time) and fear making mistakes because of what this might imply about their value as a person. Many research studies have found that the most effective treatment for OCD-related perfectionism and social anxiety is cognitive behavioral therapy (CBT).  If you have one of these conditions, find a therapist who uses exposure and response prevention (ERP), a specific form of CBT that will be an important part of your recovery.  ERP will help you challenge your perfectionistic beliefs, which will reduce your symptoms and make you less vulnerable to future relapse.  I should note that although ERP is commonly thought of as an OCD-specific intervention, its principles apply readily to social anxiety treatment. As I have discussed earlier, ERP has two main components: exposure – purposely doing activities that are designed to elicit your anxiety response prevention – actively resisting the urge to complete a ritual You should only complete exposures if you are able to maintain good response prevention while doing so.  This applies both to external/behavioral rituals, as well as mental rituals.  Even the most challenging, high-level exposures will be ineffective if you are not maintaining good response prevention.  Moreover, ritualizing during your exposures will actually strengthen your anxiety in the long run.  In some cases, acting in a self-deprecating...
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Perfectionism in OCD: When the pursuit of success turns toxic

There is more than one type of perfectionist. First, there is the adaptive perfectionist.  This perfectionist is the prototypical workaholic student/employee who goes above and beyond expectations.  This person is intelligent, hard-working, dependable, and passionate about meeting or beating deadlines.  He or she sets high personal standards of performance and has an attention to detail that is appreciated by (and often draws accolades from) others. However, not every perfectionist resembles this prototype.  There is another type of perfectionism that might be affecting you or someone you know.  This perfectionist doesn’t quite look like the adaptive perfectionist, and based on his or her observable behavior, their perfectionism might not even be readily apparent. Nevertheless, the maladaptive perfectionist shares many features in common with the adaptive perfectionist.   Similar to the adaptive perfectionist, the maladaptive perfectionist is likely to be intelligent and articulate.  He or she has very high standards and feels passionately about the importance of hard work.  Yet in contrast to the adaptive perfectionist, the maladaptive perfectionist often misses deadlines and fails to deliver an exceptional work product (or, in some cases, any work at all).  He or she might even be considered lazy or irresponsible by others.  However, the maladaptive perfectionist is usually far from lazy; despite a lack of tangible output, he or she often spends an overabundance of time and effort working. How is this possible?  The maladaptive perfectionist often gets stuck in repeating tasks and has difficulty finishing projects.  He or she may repeatedly recheck or revise their work.  However, despite these efforts, the product never quite feels “good enough.”  The ideas are nearly there, but they never feel fleshed out or polished in a way that gives the individual enough internal satisfaction to achieve closure and bring the project to completion.  Alternatively, the person may suffer from intellectual paralysis due to an over-concern with living up to their own potential, fear of failure, or a fear of disappointing others (e.g., teachers, parents, loved ones).  This intellectual paralysis may lead to complete avoidance, and this avoidance often becomes chronic and difficult to change. For some individuals, maladaptive perfectionism is actually obsessive-compulsive disorder (OCD).  This type of OCD is tricky because it can be more subtle than other types of OCD.  Because it doesn’t resemble many of the other types of OCD with which people are commonly acquainted (hand-washing, checking locks, etc.), it often goes undetected and untreated.  This can be frustrating and depressing for sufferers....
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Don’t feed the reassurance monster…and other quick tips to help your child fight OCD

Many excellent parents struggle with how to appropriately parent their child with obsessive-compulsive disorder (OCD). Unfortunately, this process is rarely straightforward and is often counter-intuitive, which leaves many parents feeling anxious and confused. As a psychologist in Palm Beach, Florida, I work closely with kids, teens, and parents throughout the greater Palm Beach, Fort Lauderdale, and Miami areas on strategies for recovering from OCD. Consider the following set of ground rules for parenting your child with OCD.  The strategies you adopt as a parent can mean the difference between reducing your child’s symptoms or giving these symptoms room to grow. 1. Remind yourself that OCD is based on emotion rather than logic. Many parents get tripped up and frustrated by the many illogical forms that OCD takes. If you consider OCD to be a logical process, you’ll inevitably become vulnerable to using lecturing and/or chastising as your primary intervention. However, if you correctly recognize and label OCD as illogical, it is much easier to implement behavioral strategies that are exposure-based, and will decrease symptoms over time.  One example of an exposure-based strategy might be eating dinner while intentionally making statements related to contamination.  These might include, “Pass me the germy mashed potatoes” or “I hope the roast beef has extra e.coli tonight.”  Although many people (with or without OCD) might be uncomfortable thinking about germs while eating, this strategy allows us to directly challenge OCD-related cognitions. 2. All primary caregivers (and all household members, if possible), should adopt consistent policies for responding to OCD. In two-parent households, parents must agree on how OCD-related situations will be addressed. If a child splits time among multiple households, it is critical that all primary caregivers implement similar strategies. Failure to adopt a consistent plan will likely increase your child’s anxiety, increase household conflict, and lead to splitting among caregivers. 3. Don’t “Feed the Reassurance Monster.” In most cases, regardless of the form it takes, OCD is about wanting certainty in situations that are fundamentally uncertain. When a child washes his or her hands repeatedly, he or she is trying to be certain that all potential germs have been eliminated. When a child repeatedly checks locks, he or she is trying to be absolutely certain about issues of safety. When we, as parents, repeatedly provide reassurance, we make it more difficult for our children to learn to be content in an uncertain world. Examples of “Feeding...
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ERP therapy for OCD: Shifting from destructive to constructive to gestalt notions

Here’s a question for you: Is ERP fundamentally a destructive or constructive process? I think that many people naturally conceptualize it as more of the former than the latter. They conceive of ERP as being the process by which we can “unlearn” or “weaken” maladaptive associations. We learn, through repetition, to no longer be afraid of those things that previously incited fear. On the surface, this appears to be a notion predicated on destruction. In actuality, it is not. If you ever take the time to refer back to the basic animal literature on fear learning and fear “unlearning”, you’ll find that associations appear to be weakened largely as a consequence of new learning taking place. This new learning competes with (and weakens the expression of) previous learning. It is this process that accounts for spontaneous recovery, difficulties with generalization, and other such phenomena. As anyone who has completed a successful course of ERP can attest, the fear doesn’t truly just disappear. Rather, it’s replaced by a growing sense of agency, purpose, and a confidence in one’s ability to cope. Sure, the fear is, in essence, weakened. However, more importantly, one has learned to better tolerate doubt and uncertainty, to be better at living without knowing. This gestalt, which emerges from destruction conjoined with construction, is the true basis of change. Questions? Comments? Sound off below. …or continue the discussion on Facebook, Twitter, or...
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Advanced ERP for OCD: how subtle rituals can limit your progress

As any good psychologist experienced in treating OCD can tell you, the most effective treatment for OCD is exposure and ritual prevention (ERP).  You may also see this type of therapy referred to as exposure and response prevention.  In this case, the semantics are immaterial; the concepts are exactly the same.  ERP is a type of cognitive behavioral therapy (CBT) that is based on the premise that the best way to reduce your symptoms is to practice activities designed to trigger your anxiety and then resist any urges to ritualize.  ERP has two main components: exposure – purposely doing activities that are designed to elicit your anxiety response prevention – actively resisting the urge to complete a ritual For example, for someone who worries about germs, an exposure might involve purposefully touching a trashcan and then resisting the urge to wash. Both the exposure and response prevention elements are critical for effective ERP.  Exposure without response prevention (or with poor response prevention) will not decrease your symptoms.  In fact, in some cases, exposure without response prevention can actually make your OCD stronger because you are reinforcing the idea that the only way to escape from OCD-related anxiety is to ritualize.  In essence, the more you practice your rituals, the stronger and more debilitating your OCD will become.  For most people with OCD, ERP is pretty scary at first.  You are intentionally doing the very thing that the OCD part of your brain has been warning you about.  Fortunately, that fear diminishes with repetition. As you practice ERP and gain confidence in your ability to resist rituals, the process becomes easier and your symptoms become more manageable.  Therapists who specialize in treating OCD can help you learn to practice good ERP and deal with the anxiety you may feel before (and during) an exposure.  Well-trained therapists are also experienced in being able to recognize a wide variety of rituals and avoidance behaviors, some of which you may be less able to notice yourself.  As a psychologist in Palm Beach, Florida, I work closely with kids, teens, and adults throughout the greater Palm Beach, Fort Lauderdale, and Miami areas on strategies for recovering from OCD. With consistent ERP that emphasizes both exposure and response prevention, most individuals with OCD experience a significant reduction in their symptoms. However, sometimes you can be practicing regular exposure and still not get the results you want.  If...
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OCD and DSM-V: Taking the “anxiety” out of OCD

Psychiatrists and psychologists continue to debate the fundamental nature of OCD, trying to decide whether or not OCD should continue to be classified as an “anxiety disorder.”  In some ways, OCD overlaps with other anxiety-related conditions, such as panic disorder, phobias, social anxiety disorder, generalized anxiety disorder, and post-traumatic stress disorder (PTSD).  In other ways, OCD is unique unto itself. Although the current version of the Diagnostic and Statistical Manual (the book that psychologists and psychiatrists use when making diagnoses) classifies OCD as an anxiety disorder, the next revision is likely to give OCD its own category of related conditions (see here). Regardless of your position on the conceptual issues involved in this change, there are many pragmatic benefits that arise from treating OCD-related conditions as distinct from the anxiety disorders.  For example, it is likely that this change will ultimately increase the availability of funds for OCD-related education, treatment, and research.  This will be appreciated by patients, clinicians, and researchers alike. Questions? Comments? Sound off below. …or continue the discussion on Facebook, Twitter, or...
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OCD & ECT (electro-convulsive therapy): Not a first-line treatment

If your only diagnosis is OCD and you don’t have any other complicating factors, be cautious when considering electro-convulsive therapy (ECT) for treating your OCD.  ECT can be a very helpful intervention for many types of conditions (e.g., severe depression, bipolar disorder, schizophrenia), but it is not considered to be a first-line treatment for OCD.  Unfortunately, I have encountered several individuals recently who have undergone ECT without first receiving a good trial of exposure and response prevention (ERP).  Research indicates that medication and intensive ERP should be attempted prior to undergoing ECT, unless there is a good reason why these interventions are counter-indicated. If you have OCD and you are considering ECT, consult with a psychiatrist who specializes in treating OCD.  He or she can advise you about your best course of action. Questions? Comments? Sound off below. …or continue the discussion on Facebook, Twitter, or...
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OCD guilt, shame, disgust, anxiety & depression: Why treatment sometimes fails (and what to do about it)

OCD isn’t just about anxiety. Although anxiety is certainly a prominent feature of the disorder, clinicians who only attend to anxious symptoms can easily overlook some of its other core features. As a psychologist in Palm Beach, Florida, I work closely with kids, teens, and adults throughout the greater Palm Beach, Fort Lauderdale, and Miami areas on strategies for recovering from OCD. In the patients I treat, anxiety is often accompanied by significant guilt, shame, disgust, and depression. These features are not necessarily related to, or caused by, anxiety; they can be distinct processes. If you (or your psychologist) conceptualize exposure and response prevention (ERP) as only a means to habituate to anxiety but fail to consider how treatment must also address these other features, you are likely to have a suboptimal treatment response and will continue to experience significant residual symptoms.  Furthermore, you might inappropriately label yourself as treatment refractory and pursue more invasive alternative procedures (e.g, psychosurgery or deep brain stimulation [DBS]) than may be necessary.  Research studies suggest that these procedures can be effective, but who wants to have an unnecessary, irreversible, and expensive surgical procedure? Not everyone needs to augment their ERP with interventions designed to address guilt, shame, disgust, and depression; however, it’s worth considering if you have had multiple frustrating experiences with treatment. There are certain classes of individuals who have to be particularly savvy when conceptualizing their OCD symptoms and selecting appropriate interventions. At greatest risk for potential clinical mismanagement are individuals with: Predominantly mental rituals “Pure O” OCD Harm obsessions (e.g., hit and run OCD, fear of harming others or self, fear of  losing control and acting on an unwanted thought) Sexual obsessions (e.g., fear of being attracted to an unwanted person or object, fear of being attracted to something socially unacceptable, fear of violent imagery) Scrupulosity (e.g., worry about going to hell, committing unpardonable sins) For individuals with these forms of OCD, addressing the entire sequelae of OCD is paramount.  ERP should be embedded in CBT that targets guilt, shame, disgust, depression, and other important features of the disorder.  Depending on the person, exposure hierarchies should be developed to explicitly target these features (e.g., develop a guilt hierarchy or a disgust hierarchy).  When possible, it is also very helpful for individuals to understand how certain neurobiological phenomena contribute to their symptoms (e.g., the neural basis for guilt).  This can help a person learn to better...
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OCD, ERP, & doubt sensitivity: Shattering the illusion of certainty

Many individuals with OCD hunger for certainty. It’s a craving that often can’t be easily sated. Early conceptions of OCD from the 19th century acknowledged this issue directly, in that OCD was often termed the “doubting disease.” It is this need for certainty, the need to eliminate doubt, that leads many people with OCD to perform repetitive behaviors, which are known as rituals. For example, it is doubt about whether one’s hands are sufficiently clean that leads one to engage in repetitive hand-washing behaviors. Likewise, uncertainty about whether a stove has been turned off (and worry about potentially dire consequences) can underlie checking rituals. For people with OCD who have intrusive bad thoughts (e.g., What if I secretly want to hurt a family member? What if I don’t believe in God enough and go to hell?), an inability to tolerate doubt can be devastating. This can leave a person stuck in a moral quagmire that feels hopeless. The person not only has symptoms of OCD but also is experiencing an existential crisis about their own nature. It is for this reason that many people with OCD feel confused, guilty, and alone. Unfortunately, rituals never provide a long-term solution. Although they can sometimes be helpful for reducing doubt in the moment, this relief is only temporary. Doubt will inevitably rebound, rituals will become less effective at reducing anxiety over time, and symptoms will grow. The truth is that certainty is always a mirage. We can never have complete certainty. We can never erase all traces of doubt. We don’t live in a world where that is possible. But that’s okay. We can learn to live with doubt. Coexistence is possible, and it’s probably happening right now. You just haven’t realized it. When we drive to the grocery store, are we guaranteed that we will arrive? Of course not. And yet many of us undertake that risk without even thinking about it. Chances are, if you really think about it, you can identify many examples in which you set aside your doubt and take risks. If you’re a person with OCD, you can learn to strengthen your tolerance of uncertainty through exposure and response prevention (ERP). One theory suggests that ERP works by helping the brain recalibrate its super-sensitivity toward doubt and uncertainty. Through repetition, ERP results in a more functional set point. Interestingly, the neural basis of this change can...
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Miami/Fort Lauderdale OCD support groups for adults and kids

Several support groups for individuals with OCD are conveniently located near Miami, Fort Lauderdale, and Boca Raton.  Some groups are facilitated by licensed clinical psychologists, whereas others are led by individuals with OCD.  To view current support groups in South Florida (Dade, Broward, and Palm Beach counties), visit the IOCDF”s support group page here.  Each support group listing provides information about the group’s focus, target age group, location, and leader.  Listings also contain contact information for the sponsor of the group in case you want to obtain additional information prior to attending. Please note: different support groups target different age groups and different OC-spectrum diagnoses (e.g., OCD, trichotillomania, hoarding).  Some groups are for adults only (18+), whereas others are for children and teens with OCD.  Most groups are free to the public and offer opportunities for individuals to tell their stories, share recovery strategies, and ask questions. Questions? Comments? Sound off below. …or continue the discussion on Facebook, Twitter, or...
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OCD symptoms: the obvious (and the not so obvious)

Turn on your television, and you’re likely to catch at least a fleeting glimpse of obsessive-compulsive disorder (OCD). Many popular TV shows feature characters with OCD (e.g., Emma on Glee, Monk), and it is through this lens that many members of the general population get their first exposure to OCD. Unfortunately, if your understanding of OCD is based solely on depictions in the popular media, you are likely to have a relatively limited (and perhaps, warped) sense of what OCD really is. The truth is that OCD can manifest in many different ways. Although some symptoms are more common (e.g., a fear about about germs or getting sick), other symptoms can be quite idiosyncratic and often go undetected by inexperienced psychologists. The unfortunate consequence of this is that many people with OCD don’t know that they have OCD. Instead of recognizing their symptoms as being related to OCD, they blame themselves for their symptoms. They think that the reason they have scary or unacceptable thoughts is because they are not as “good” or as “moral” as they should be. This could not be further from the truth. In my work as a clinical psychologist, I have learned that most individuals with OCD are exactly the types of people that you would want as friends or family members. They are good, honest, hardworking people who are bombarded by near constant thoughts that are unwanted and horrifying. These thoughts often prevent them from living the lives they so desperately want for themselves and for their families. There is nothing more rewarding as a therapist than helping these individuals fight their OCD and reclaim their lives as their own. Below, I have included some categories of symptoms associated with OCD. Some of these symptoms are common, whereas others are more unusual. If you or a loved one have any of these symptoms and they are affecting your quality of life, please consider consulting with a psychologist experienced in treating OCD. Exposure and response prevention (ERP) is a highly effective treatment for OCD, and it can help you reclaim the life you deserve. CLEANING/WASHING COMPULSIONS Excessive or ritualized handwashing Excessive or ritualized showering, bathing, toothbrushing grooming, or toilet routine Involves cleaning of household items or other inanimate objects Other measures to prevent or remove contact with contaminants CHECKING COMPULSIONS Checking locks, stove, appliances etc. Checking that did not/will not harm others Checking that...
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Palm Beach OCD support group

So I’m thinking about starting an OCD support group in North Palm Beach. There are many details that would have to be ironed out (location, time, etc.), but I think it’s troubling that Palm Beachers have such little access to OCD-related resources. Possibilities for the location include Palm Beach Gardens, Jupiter, Juno, or West Palm Beach. PBG is probably the front runner at this point.  Obviously, all South Florida people are welcome.  Whether you’re fighting OCD in Miami, Fort Lauderdale, Boca Raton, Boynton Beach, Lake Worth, Royal Palm Beach, Wellington, Delray Beach, Pompano Beach, Fort Pierce, Port St. Lucie, Greenacres, or beyond, we’d love to have you. If you’re interested in this, please let me know. Questions? Comments? Sound off below. …or continue the discussion on Facebook, Twitter, or...
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