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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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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Teen Social Anxiety Group (Cognitive Behavioral Therapy/Group Therapy)

Teens with social anxiety unite! In this paid treatment group, teens will support each other in developing cognitive behavioral skills to combat social anxiety. This workshop will be interactive and fun. Note: If you are an adult with social anxiety, there’s a group for you coming soon! If you’re interested, please call our office or reply to this email so that we can better gauge demand for an adult social anxiety group. With the new school year quickly approaching, there is no better time to work on tackling your social anxiety. The intent of this group is to provide a supportive environment for developing cognitive behavioral skills and completing exposures. Because social anxiety can co-occur with other types of anxiety, you do not need a social anxiety diagnosis to benefit from this group. In some cases, this group may also be helpful for individuals with obsessive compulsive disorder (OCD), body dysmorphic disorder (BDD), panic, agoraphobia, and others who may be self-conscious or concerned what others may think of them. This group will meet on Saturday (8/17/13), 11am-1pm. The fee for attending this group is $100. 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 may be held based on interest and/or may be held in conjunction with an adult social anxiety group. Participants MUST BE APPROVED BY DR. SEAY in order to attend. Future meetings will be announced via our Events calendar and email distribution lists. Space is limited, so please secure your spot today by calling our office to register. 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. Thanks, and I hope to see you at our...
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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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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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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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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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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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Does Non-Avoidance = Exposure? No! Anxiety Disorder Treatment Principles for OCD, Panic, Social Anxiety, & Phobias.

Anxiety Principle of the Day: Non-Avoidance is not equivalent to exposure. Although exposure is predicated upon the purposeful non-avoidance of anxiety-related stimuli, non-avoidance of anxiety triggers is not equivalent to exposure. What is non-avoidance? I liken non-avoidance to being in a particular place at a particular time. Essentially, it involves being in a situation in which your anxiety is triggered by proximity to anxiety-related cues. Non-avoidance requires no action on your part aside from being physically present in the situation. As such, like a hole, it’s possible for a person to accidentally stumble into a non-avoidance exercise. Isn’t that the same thing as exposure? No. Exposure is not merely a situation, and as such, it can’t be entered into by accident. Although exposure therapy has situational elements, it is a dynamic experience that has best practices, as well as Do’s and Don’ts. It is also based on a specific “philosophy of doing” that has essential cognitive components. When done properly, exposure is a personal, deliberate, and reasoned assault against your anxiety. In contrast to simplistic non-avoidance, exposure is premeditated and thoughtful, it has cognitive and emotional goals, it is prolonged, and it is grounded in pragmatic application of sound theoretical principles. That can be a tall order for individuals new to exposure. That is why I often suggest that people begin exposure therapy under the supervision of a therapist who specializes in anxiety disorders. When I see a patient for the first time in my Palm Beach, Florida office who has struggled with chronic anxiety, they often tell me that they’ve completed “exposures” in the past and that “exposures” didn’t help them get better. In fact, these patients are most often misconstruing non-avoidance exercises for exposure exercises. They might have been in the right place at the right time, but they weren’t doing the right types of things while they were there. Let me illustrate the difference between non-avoidance and exposure. Suppose I have arachnophobia, and I have decided to overcome my fear of spiders. To accomplish this end, I will no longer actively avoid spiders. I will operate according to a new set of principles that involve not letting spiders dictate my behavior. I’ll go outside when I want to, and I’ll even tolerate being in the same room with a spider when I see one. These are sound non-avoidance guidelines. The difference between non-avoidance and exposure is...
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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 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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Fear, Doubt, Uncertainty, ERP, & the Monster Under the Bed

Everyone I know has, at some point, had to deal with the monster under the bed. Some do it with grace. Others falter. I’ve always been clumsy. I can vividly recall many terrified nights from my childhood, when I would lie rigidly in my bed, utterly paralyzed by fear. Afraid to make the slightest movement, to breathe, to call out for my parents…lest I be detected by IT. The pounding of my heart would be so loud in my ears, and my breathing so ragged, that I could swear the entire house could hear me. And yet…no one came to help. The moment would stretch out like taffy. At some point, my raw fear would ever so subtly decline, freeing me up to end the stalemate in one of several ways. Some nights, I would call out for help. On other nights, I would launch myself out of bed and across the room to flip on the light-switch, banishing the darkness with welcome illumination. However, in retrospect, the most helpful nights were those nights I didn’t look. On those nights, my stubborn streak would embolden me to hunker down and not look. I would sit in bed with fear, doubt, uncertainty, and resolve. “Bring it on, monster.” And you know what? The monster never came. My monster doesn’t bother me anymore. Does yours? Share below… …or continue the discussion on Facebook, Twitter, or...
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Mindfulness & ACT-based therapy: Questioning “I hurt; therefore, I suffer.”

Mindfulness & ACT-based Approaches to Therapy Mindfulness & Acceptance and Commitment Therapy (ACT)-based approaches to treatment might (Hayes, Strosahl, & Wilson, 2003) ask you to consider the truth of the following statement: I hurt; therefore, I suffer. Most of us would probably agree that suffering is usually borne out of hurt. But this doesn’t mean that pain, discomfort, or unwanted emotions necessarily lead to suffering. In truth, many hurts do not lead to suffering. Pain and suffering are distinct entities that exist on two entirely different planes. Pain is based on an experience, whereas suffering is based on how we perceive that experience. In many cases, we may not be able to sidestep pain or hurt; however, suffering may be a different matter. Pain Think about the last time you felt physical pain. Maybe you’re feeling it right now. You might consider the aches of tired joints, the familiar sting of chronic pain, the drawn-out burn after a workout, or even the experience of stubbing your toe. Consider what your pain feels like. Where is it located? Is it a sharp or dull pain? Constant or throbbing? Growing in intensity or fading? Take a moment to really look at your pain. Examine it. Probe it. Accept it as it is. Own it. To do otherwise is to deny your own experience. Acceptance of pain does not mean that you have to like it. It doesn’t mean that you hope for the pain to continue or to increase in intensity. It simply means that you’re not denying the reality of your current moment. If you’re experiencing pain, you’re experiencing pain. Suffering What, then, is suffering? Suffering comes from an appraisal of pain, from an unwillingness to accept it. In many cases, suffering begins when we make certain types of statements or ask certain types of questions: Why is this happening to me? When will this end? I can’t take this. These types of statements lead to contradictions that cause suffering. Think about it.      Why is this happening to me?      I don’t know why this is happening to me…but it is.      When will this end?      I don’t know when this will end…but it’s happening to me right now.      I can’t take this.      I feel I can’t take this…but yet, here I am. These failures to accept your current experience cause suffering. Pain may be a necessary prerequisite for suffering, but it...
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Social Anxiety Treatment: CBT & Intentional Mistake Practice (an example)

When I was a kid, one form of mischief that was briefly popular in my neighborhood was crank calling strangers. Usually, the bravest kid in the group would pick up the phone, and with the encouragement of all the other kids in the room, would dial a random telephone number. A brief, very Bart Simpson-esque conversation would then ensue. Usually it would go something like this: Kid: Hello, ma’am. I am conducting a brief survey for the Grocer’s Association. Do you have a minute to answer a quick question? Stranger: Of course. How can I help you? Kid: I was wondering if you have Sara Lee in the freezer. Stranger: Why, yes I do. Kid: Well then let her out!!! We would then bust out in laughter and hang up the phone, leaving the recipient of our phone call both perplexed and annoyed. This process would typically repeat itself two more times before we got distracted by something more entertaining. It’s pretty interesting to consider in retrospect.  What strikes me is this: Typically, the bravest kid in the group would make the first phone call. However, once the ice was broken, kids of nearly any temperament would then follow. Even kids who were shy by nature became emboldened after making just a few phone calls. In this situation, just as in any other social anxiety-related situation, practice helped.  Even if you feared potential embarrassment at first (e.g., freezing up, not knowing what to say, stuttering, tripping over your words), these fears quickly dissipated with practice.  Moreover, the social nature of the prank was able to quickly transform what might have been a troubling, socially-awkward situation into something more game-like.  It’s simply harder to feel afraid when you’re trying to one-up your friends. Of course, friends are also good at helping keep anxiety in check. For every kid prone to catastrophizing, there’s another laid-back kid who would set the record straight. Social Anxiety & Intentional Mistake Practice: CBT in Action As I mentioned in an earlier blog post, one key to recovering from social anxiety is something called “Intentional Mistake Practice” (IMP).   For some individuals with social anxiety, engaging in intentional mistake practice can be one helpful component of cognitive behavioral therapy (CBT) for social anxiety.  IMP gives you the experiences you need to recalibrate your thinking about social situations. In reality, other people are far less critical and are less aware of our behavior...
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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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Therapy as Science: You + Your Therapist + Scientific Method

I consider myself a scientist.  I wear this hat officially when conducting research, but I also wear it every time I sit with a patient.  In my research, my science is pretty self-evident: I identify a research question, develop falsifiable hypotheses, and then collect quantifiable data to see whether or not the phenomenon I’m studying behaves the way I think it does. A very similar process unfolds when I work with you in my clinic.  However, from your vantage point, you might not realize it right away.  Nevertheless, we are two collaborative empiricists. Most often, you will define the “research question”.  Usually, this is the very reason that you’re coming to see me.  Sometimes the questions we think we’re asking are not necessarily the ones we should be asking.  For example, questions like, “Why is this happening to me?” are often disguised ways of asking, “How can I change this?”  If that’s the case, I’ll help you refine your question.  Our questions will also be guided by the data you bring to your initial assessment.  These data points include your responses to various questionnaires, as well as other important information we discuss (e.g., current symptoms, symptom history). Next, we’ll develop hypotheses about which strategies are most likely to be helpful for you.  Since I’m an evidence-based medicine kind-of-guy, I’ll let you know what research studies say about the types of interventions that are most likely to be effective for resolving your “research question”. Although not everyone is the same and responds to the exact same treatment protocol, we’ll let science be our guide.  For example, research studies tell us that cognitive behavioral therapy (CBT) is great for reducing symptoms of depression, whereas something called exposure and response prevention (ERP) is particularly good for treating OCD. We will then implement our plan and collect data to make sure we’re moving in the right direction.  These data points include answers to questions, such as: How is your anxiety changing as you are getting more practice with exposure? What are you doing now that you’ve avoided in the past? How does your day-to-day life reflect your personal values? How effective are you at work, at home, and in social situations? How many panic attacks are you having per week/month/year now compared to the past? These are just a few simple questions (there are many, many  more), but as you can see, each...
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The Power of Being Selfish: Selfishness as a Key to Mental Health

I’m about to tell you something that your mother might not approve of…so for those of you sensitive souls out there, you might want to click on something less controversial. Here it is: It’s okay (and sometimes even essential!) to be a little bit selfish. Conventional wisdom, and our parents, often tell us that it’s not okay to be selfish.  If you want to be an effective parent, you must learn to put your kids’ needs before your own.  Likewise, to be a good spouse, you must learn to  honor your partner’s needs.  These are truths, and if you aren’t living these truths in your daily life, it is likely that your relationships have suffered. However… As with anything, these truths must not be taken to extremes. I found myself thinking about this idea over the weekend as I was talking to a friend going through a particularly challenging situation.  In some cases, to be healthy, wealthy, and wise…we need to make specific efforts to honor our own needs.  If we don’t, we run the risk of completely burning ourselves out and suffering the ill effects of depression, stress, and anxiety. What do I mean by honoring our own needs? Some examples of this might include: Celebrating your own successes at work, school, and home. Recognizing and utilizing “me time” when needed. Setting and enforcing appropriate boundaries with others. Allowing yourself to feel pride in something you do well. Learning how to gracefully say “no” to others. Letting other people know your true opinions and feelings. Accepting help from others (even when you could do the same job yourself). Technically, these things are selfish. But they are also essential ingredients for health, success, and wisdom. Go tell your mother it’s okay to be selfish sometimes.  She’ll be grateful. Questions? Comments? Sound off below. …or continue the discussion on Facebook, Twitter, or...
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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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Specific phobias: symptoms & CBT treatment (reader question)

Question: Basically, I wanted to know from an expert, what can a phobia do to a person? How does it affect them mentally? Also I see that you’ve got a new treatment philosophy — is there any way you can talk me through it? One of the goals of cognitive behavioral therapy (CBT) is to learn to better understand the interrelationships among thoughts, feelings, and behaviors.  Once you understand how these things are connected, it gives you a lot of power to implement change. Most people who seek therapy do so because they are experiencing an emotion they don’t want to have.  In the case of depression, the person might feel sad.  In the case of a phobia, the person might feel scared.  People often have trouble modifying these feelings directly because emotions tend to be somewhat involuntary.  If you’re sad or scared, there isn’t really a switch you can flip to feel better.  We, as humans, can’t modify our emotions through sheer act of will.  Fortunately, CBT gives us the tools to modify our thoughts and behaviors, which then indirectly affect how we feel.  Relative to our emotions, we have much more control over our behavior and (to a somewhat lesser extent) our thoughts.  Through behavioral and cognitive changes, we can effect changes in how we feel. My treatment philosophy acknowledges this explicitly.  If you are trying to overcome a fear of heights (acrophobia), for example, you could talk about your fear everyday for the rest of your life.  However, talk alone would never help you overcome your fear.  When it comes to overcoming an anxiety disorder, there’s a place for talking, but there’s a larger place for action.  When I work with people on overcoming fears, I help them understand what creates and maintains fear, but my larger goal is to help them develop the confidence and willingness they need to face the fear directly.  We then go out together in the real world to challenge the fear.  We would proceed in a very systematic way (going from easier “exposure” exercises to more challenging ones), but if the person really wanted to get a handle on the fear, we would eventually go up in skyscrapers, ride roller coasters, take a plane ride, etc…whatever we would need to do to help the person overcome his/her phobia.  There are many unique in-vivo exposure opportunities throughout the greater Palm Beach, Fort...
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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 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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Palm Beach trichotillomania (trich) support group

Okay, so in addition to the possible Palm Beach OCD support group, I am also thinking about forming a trichotillomania (trich) support group. For those of you who aren’t familiar with trichotillomania, it’s an impulse control disorder that is associated with compulsive hair-pulling behaviors. It is likely that trich will soon be officially reclassified as an OC-spectrum disorder in the upcoming DSM-V, which is the manual that psychiatrists and psychologists use when making mental health diagnoses. Possibilities for the group location include Palm Beach Gardens, Jupiter, Juno, or West Palm Beach. Miami and Fort Lauderdale locations might also be considered, but these are unlikely at this point. 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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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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