Body dysmorphic disorder symptom areas vary between individuals but commonly focus on the skin, hair, weight, and specific facial features.

Symptoms of Body Dysmorphic Disorder (BDD)

Body dysmorphic disorder (BDD) is a somatoform disorder that closely resembles obsessive-compulsive disorder (OCD). Symptoms of body dysmorphic disorder include excessive concern about perceived physical flaws, defects, or imperfections.

Individuals with body dysmorphic disorder become obsessed with these unwanted aspects of their appearance and perform a variety of rituals and avoidance behaviors in order to disguise or conceal these “flaws.” BDD symptoms typically result in extreme distress and a variety of social and occupational difficulties.

Body dysmorphic disorder symptom areas vary between individuals and commonly focus on the skin, hair, weight, and specific facial features, such as the nose (Philips, 2005).

In The Broken Mirror (2005), Dr. Philips breaks down the frequency of different types of BDD concerns:

In my South Florida (Palm Beach County) psychological practice, I often treat individuals with body dysmorphic disorder whose BDD symptoms focus on specific facial features or skin quality.  They often worry about facials scars, pores, dimples, moles, birthmarks, skin tags, hair, wrinkles or lines, under-eye circles, or general facial symmetry.  Some men have symptoms that include a preoccupation with muscle growth and development. This is sometimes referred to as muscle dysmorphia, or “manorexia”, and often involves a preoccupation with muscle symmetry and fears about being “too skinny” or “too small”. Regardless of the body area of concern, BDD involves appearance-related perfectionism.

For people with body dysmorphic disorder, concerns about body symmetry are quite common.  Individuals may worry about the symmetry of specific body parts (breasts, buttocks), facial features (eyes, eyebrows, ears), or the distribution of body hair.  Other individuals experience excessive concern about scarring from elective cosmetic procedures or enhancements (e.g., over-concern about the appearance of one’s breasts following breast augmentation).

Symptoms of body dysmorphic disorder are maintained by rituals and avoidance behaviors. These behaviors are often targeted in treatment of BDD in the context of exposure and response prevention (ERP). Although ERP is traditionally considered a treatment for obsessive-compulsive disorder, ERP is also an effective treatment for BDD.

Body Dysmorphic Disorder (BDD) Avoidance Behaviors & Rituals

• Social anxiety, isolation, and avoidance.
• Avoidance of dating and sexual intimacy.
• Avoidance of places with bright, intense lighting that might highlight or reveal perceived flaws.
• Avoiding particular activities like swimming.
• Avoiding exercise (or other sweat-inducing activities) or (in other cases) over-exercising.
• Performing facial exercises or other exercises targeting specific BDD concerns.
• Staying at home during rainy or windy days.
• Limiting or avoiding eye contact with others.
• Keeping the face in profile to prevent others from noticing assymetries.
• Spending excessive time in preparing to go out.
• Repeatedly checking in the mirror or inspecting one’s appearance.
• Repeatedly applying/reapplying make-up to modify or disguise any perceived defect.
• Repeatedly brushing or styling the hair.
• Repeatedly shaving the skin.
• Wearing bulky/oversized clothing to disguise the defect.
• Limiting contact with real-life friends (but potentially not online friends).
• Avoidance of situations where photographs or videos will be taken.
• Checking appearance in mirrors and reflective surfaces.
• Touching or inspecting perceived flaws.
• Wearing hats or wigs.
• Use of hair-growth products like Rogaine.
• Reassurance-seeking (asking other people if they can see the defect).
• Trying to convince other people of the defect’s existence.
• Closely monitoring other people’s reactions and eye movements in social situations.
• Skin-picking, rubbing, or smoothing the skin.
• Tweezing and plucking hair.
• Getting frequent haircuts or frequently trimming one’s own hair.
• Avoiding form-fitting clothing or any clothing that feels restrictive or puts pressure on the skin.
• Excessively dying the hair.
• Repetitive surgical alterations of one’s appearance.
• Excessive use of products designed to prevent aging or restore one’s appearance.
• “Flexing and checking”, excessive exercise, excessive eating, and the use of anabolic steroids or growth hormones (in muscle dysmorphia).

Want to learn more about BDD? Read my previous post that provided an overview of body dysmorphic disorder.

Questions? Comments? Do you experience symptoms of body dysmorphic disorder (BDD) that weren’t included above? Sound off below.

…or continue the discussion on Facebook, Twitter, or Google+.

Body Dysmorphic Disorder (BDD) is an OCD-like syndrome that involves hyper-attention to one or more perceived bodily defects, imperfections, or flaws.

What is Body Dysmorphic Disorder (BDD)?

Body dysmorphic disorder (BDD) is not formally classified as an anxiety disorder; however, it shares many overlapping features with anxiety disorders like obsessive-compulsive disorder (OCD).

In contrast to OCD which typically focuses on specific external feared outcomes, body dysmorphic disorder involves hyper-attention to one or more perceived bodily defects, imperfections, or flaws.  BDD “flaws” are experienced as distressing and intolerable.

In some cases, the imperfections that bother individuals with body dysmorphic disorder can be perceived by other people, but BDD magnifies and distorts these imperfections in the eyes of the sufferer.  In other cases, individuals with BDD notice and attend to “flaws” that cannot be readily perceived by others.  Regardless of the form of one’s symptoms, body dysmorphic disorder is associated with extreme distress and shame.  Moreover, because BDD-related “flaws” are often perceived as being permanent, inescapable, or un-fixable, many individuals with body dysmorphic disorder experience hopelessness, depression, self-loathing, and suicidal thoughts. Due to shame about their appearance, many people with BDD go to great lengths to keep their symptoms a secret.

Individuals with body dysmorphic disorder often use mirrors to check or scrutinize their appearance.  They also engage in a variety of avoidance behaviors in order to mask or hide their perceived defect(s) from others.  They often avoid going out in public (e.g., skipping class or work), limit involvement in situations in which they might be the center of attention (e.g., dating), or spend excessive time trying to camouflage, disguise, or alter their appearance.  Preparation for leaving the house may involve elaborate grooming behaviors that span hours every day.

Although many people have sensitivities about certain aspects of their appearance, typical sensitivities do not reflect BDD.  By comparison, symptoms of body dysmorphic disorder are extremely distressing and potentially disabling.

The checking and grooming rituals that characterize body dysmorphic disorder resemble the compulsive behaviors found in obsessive-compulsive disorder.  However, there are some notable distinguishing features between individuals with OCD and BDD.  One of the major differences between OCD and BDD is the degree to which one recognizes his/her rituals as excessive or unreasonable.  Although individuals with OCD experience extreme anxiety about their particular feared outcome (e.g., fear of getting sick, fear of hitting someone with their car), they often recognize that their rituals are excessive.  This is particularly true when the individual is not actively exposed to a symptom trigger.

In contrast, body dysmorphic disorder tends to be associated with poorer insight (Veale, 2004).  Most individuals with BDD are convinced that their “defects” are obvious to everyone. They often are quite certain that these “flaws” make them appear hideous, ugly, or deformed to other people.  Because these beliefs are so strongly held,  the need to disguise or mask the appearance transcends most situations and feels nearly impossible to resist.  People with body dysmorphic disorder fear that if they do not hide their perceived defect, they might suffer extreme embarrassment or shame. Regardless of how others might actually react, feeling physically exposed is experienced as being intolerable.

Is Body Dysmorphic Disorder (BDD) a form of vanity?

Absolutely not.

Individuals with body dysmorphic disorder are not vain, although individuals unfamiliar with the condition might mistakenly assume so on the basis of the amount of time individuals with BDD spend primping and grooming.

Vanity involves taking pride in one’s appearance. In contrast, BDD involves hating one’s appearance.

Whereas grooming behaviors in vain people are attempts to appear more attractive or desirable, BDD compulsions reflect attempts to escape or control unwanted feelings of ugliness.  The checking and grooming rituals common in BDD are experienced as distressing rather than enjoyable.

Many people with BDD are humble, likeable people who experience perceptual anomalies that cause them to misprocess information about themselves.  Unfortunately, these perceptual abnormalities cause them to mistakenly consider themselves ugly, deformed, or hideous.

What causes Body Dysmorphic Disorder (BDD)?

Why do people develop BDD?  It is thought that people with body dysmorphic disorder have information processing abnormalities (Yaryura-Tobias, Neziroglu, & Torres-Gallegos, 2002).

People with BDD appear to misprocess information about their own appearance. Essentially, when they look in the mirror, they over-attend to information about flaws.  They have a hard time processing reflections holistically and instead get stuck in over-analyzing and trying to “fix” one specific aspect of their appearance.  Because they themselves over-attend to information about their own appearance, they assume that other people will do likewise.

People with body dysmorphic disorder also appear to incorrectly process emotional information about other people.  In comparison to people without BDD, people with BDD are more likely to perceive neutral expressions as being angry, hostile, or rejecting (Buhlmann, Etcoff, & Wilhelm, 2006).

BDD is also associated with learning-related factors. The avoidance behaviors and excessive grooming rituals that characterize BDD prevent people with the disorder from having the types of “corrective learning experiences” necessary to resolve their symptoms.  Because individuals with BDD only get social feedback about their appearance after they have spent hours doing “damage control”, they mistakenly assume that their rituals are necessary to keep others from noticing their flaws.  These compulsions are thus reinforced and perpetuated.

Body dysmorphic disorder also appears to be genetically-linked. Although BDD affects only about 2% of the general population (Rief, Buhlmann, Wilhelm, Borkenhagen, & Brahler, 2006), about 8% of individuals with BDD have another family member with BDD (Bienvenu et al., 2000). Moreover, about 7% of individuals with BDD have a first-degree family member with OCD (Phillips, Gunderson, Mallya, McElroy, & Carter, 1998).

How is Body Dysmorphic Disorder (BDD) treated?

Effective treatment of body dysmorphic disorder typically addresses all of the above factors through a combination of cognitive therapy and behavioral exposure.  BDD treatment often has elements that resemble exposure and response prevention for OCD.

When I treat BDD in my South Florida psychological practice in Palm Beach County, we begin with cognitive therapy. We then progress to building an exposure hierarchy that involves gradually decreasing avoidance behaviors and resisting rituals while increasing activities that reflect one’s goals and values.

In future posts, I’ll talk more about the symptoms of BDD and the approach to treatment I use in my Palm Beach practice.

Questions? Comments? Struggling with body dysmorphic disorder (BDD)? Sound off below.

…or continue the discussion on Facebook, Twitter, or Google+.

Answering "What If...?" questions is an anxiety-related avoidance behavior that involves overpreparation.

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 answering what ifs is time wasted. How would you rather spend your time? Rehashing answers to (likely) irrelevant questions, or doing something that will actually help you recover from your anxiety disorder?
• What ifs multiply when you engage with them. The more you answer what ifs, the more what ifs will pop up to take their places (think about the paintbrushes in the Sorcerer’s Apprentice).
• You never learn to trust yourself.  Over-preparation reinforces the idea that you won’t be capable of dealing with stressors when they spontaneously arise.  As such, in the long run, answering what ifs increases feelings of helplessness and dread.

Worry and what if questions do not actually prepare you to deal more effectively with situations; they just temporarily make you feel better.  The only real consequence of exhaustive preparation is that you miss out on experiencing the current moment. Instead, you’re living in (and engaging with) a fantasy.

Time is finite.

The most unfortunate consequence of catering to what-ifs is that you end up spending your life preparing for disasters that may never materialize.  Moreover, the sacrifices you make to “feel prepared” never actually work. You never feel adequately ready…in fact, you likely feel even more out of control.

How to Deal with What If Questions & Worry

The best way to deal with what-if’s is to acknowledge them but resist efforts to mentally solve them.  The reason this is helpful is because it’s based on acceptance of uncertainty.

When you feel an urge to answer a what if, avoid coming up with potential solutions and work on accepting that you’ll cope with the situation when it actually arises.  It’s also helpful to develop a script like the following (note: this script was written to help deal with symptoms of sensorimotor OCD):

“Thank you, OCD, for pointing out that I might have these symptoms forever. It’s certainly possible. I guess I’ll just have to deal with that when it happens. In the meantime, if I have to live with these symptoms, I might as well work on becoming less frightened/annoyed by them.”

That’s it.  If the script feels too abrupt, that’s good.  It’s supposed to be brief so that it doesn’t sideline you from your life.

Write out your script on a coping card and review it when needed.  You could also make an audio recording of your script and load it on your iphone/ipod, smartphone, computer, or car stereo.

If you find yourself asking, “What if I write the wrong script and it doesn’t work?” reread the above section “How to Deal with What If Questions & Worry.”

Questions? Comments? Struggling with anxiety related to what ifs and life’s other worries? Sound off below.

…or continue the discussion on Facebook, Twitter, or Google+.

Hit-and-run OCD involves the fear of causing accidental injury or death while driving.

Fear of Driving

Hit-and-run OCD, or motor vehicle accident OCD, is distinct from other syndromes that involve anxiety about driving or the fear of car accidents. Hit and run OCD differs from panic- or agoraphobia-related driving avoidance, in which individuals fear driving due to the possibility of having a panic attack while in the car. Diagnosis of hit and run OCD is slightly more complicated in cases in which one fears “losing control” while driving, as this symptom can reflect either panic or OCD. In the case of panic, this fear is based on panicking and “losing control” or “going crazy”, whereas in OCD this fear is based on acting on an unwanted impulse (e.g., impulsively swerving).

Hit and run OCD differs from “driving phobia” largely in terms of the rituals/compulsions that are present in OCD. Driving phobia involves more generalized fears. MVA-OCD also has a different symptom profile than post-traumatic stress disorder (PTSD) which might develop following a car accident and include flashbacks and other PTSD symptoms.

Symptoms of “Hit and Run” OCD

Hit-and-run OCD resembles other forms of checking OCD.  Just as checking a stove is used to prevent fire, checking for accidents while driving is a way of preventing (or reducing the severity of) accidental injury or death.  A common form of checking is driving back along the same route in order to scan for victims.

Unfortunately for sufferers, this compulsion actually creates yet another opportunity for having caused an accidental death or injury.  Despite driving along the same road multiple times, the potential for having missed something remains.  Relentless OCD doubt and uncertainty persist.  Many individuals get stuck in checking loops that span many minutes or hours until exhaustion and/or distress make further checking impossible.

Symptoms of hit and run OCD are time-consuming, distressing, and often debilitating.  Let’s review some of the most common symptoms of hit and run obsessive compulsive disorder (OCD).

Common Rituals in Hit-and-Run OCD

Similar to other forms of checking OCD, hit-and-run OCD involves checking and reassurance rituals. These rituals include:

• Circling back and checking for victims/bodies.
• Looking in the rear-view mirror for signs of an accident.
• Looking in the rear-view mirror to assess the reactions of other drivers (e.g., to see if other cars have swerved or pulled over).
• Listening intently while driving in order to hear screeching tires or the sounds of someone who has been hurt.
• Listening for emergency sirens (i.e., from ambulances, police cars, or other emergency vehicles).
• Monitoring the road for bumps that might signal having hit someone.
• Pulling over to the side of the road to look into ditches or gullies for injured people.
• Holding the steering wheel tightly in order to be able to react more quickly.
• Compulsively checking/readjusting mirror positions.
• Compulsive car maintenance (e.g., checking tire pressure).
• Reassurance rituals involving other passengers.
• Asking other passengers questions about whether or not someone has been hit.
• Watching other passengers’ reactions as a way of reassuring oneself that no pedestrians have been injured.
• Mental Rituals.
• Reassuring self, “No one was hit.”
• Reassuring self, “I’m a safe driver.”
• Reassuring self, “Nothing bad is going to happen.”
• Reassuring self, “I’ve driven this route a million times and nothing bad happened.”
• Mentally replaying, reviewing, or retracing one’s driving route.
• Mentally reviewing evidence that indicates that no accident has occurred.
• Praying.
• Thinking “safe thoughts.”
• Replacing “dangerous” thoughts with “good” thoughts.
• Planning what to say to the police if they show up investigating a hit-and-run incident.
• Planning what to say to your victim is s/he survives.

Avoidance Behaviors in Hit and Run OCD

Hit and run OCD is often associated with a wide range of avoidance behaviors. Common avoidance behaviors include:

• Avoiding driving entirely.
• Avoiding schools or neighborhoods where children play.
• Driving only when other people are in the car (to get reassurance that no one was hit).
• Driving only when one is alone (to prevent distraction).
• Driving in silence (i.e., without the radio on) in order to hear the cries of someone who might be injured.
• Avoiding night driving or driving in the rain.
• Avoiding “dangerous lanes” on the highway.
• Driving only on back roads.
• Not driving in unfamiliar places.
• Consolidating errands so that one doesn’t have to leave the house as often.
• Limiting driving distances and staying close to home.
• Avoiding cell phone use or other forms of distracted driving.
• Driving below the speed limit.
• Avoiding parking lots.
• Avoiding busy intersections.
• Avoiding seeing or hearing about car accidents in movies or on TV.

Feared Consequences in Hit-and-Run OCD

Feared consequences associated with hit and run OCD vary. Although the most obvious feared consequence is the actual death or injury of a victim, potential emotional consequences may cause even more distress. For example, individuals often fear the prospect of harming someone because they can’t imagine living the rest of their lives with unrelenting guilt. Common feared consequences include:

• Fear of something falling off your car and causing an accident.
• Fear of killing someone.
• Fear of maiming someone.
• Fear of going to jail.
• Fear of feeling unrelenting guilt over having killed someone.
• Fear of being “irresponsible” or “negligent”.
• Fear of having your life “ruined.”
• Fear of being perceived as “a horrible person.”
• Fear of getting convicted of manslaughter and “ruining” the lives of your friends and family.
• Fear that others will condemn you for what you’ve done.
• Fear of having to face the family members of your victim.
• Fear that life will never be the same.
• Fear of committing an unforgivable crime.
• Fear of unrelenting depression and possible suicide.
• Fear of having to face your victim (if s/he survives).

Effective treatment of hit and run OCD should be based on exposure and response prevention for OCD.  In my South Florida (Palm Beach) psychological practice, I treat many individuals with hit and run OCD and other harm-based obsessions. Treatment involves eliminating avoidance behaviors, resisting rituals, and purposefully tackling your feared consequences according to a personalized anxiety hierarchy.

Questions? Comments? Do you experience symptoms of hit-and-run OCD? Sound off below.

…or continue the discussion on Facebook, Twitter, or Google+.

Scrupulosity is a form of religious OCD that often involves having blasphemous or unacceptable thoughts about God.

What is Scrupulosity?

Scrupulosity is a form of obsessive-compulsive disorder (OCD) characterized by religious and/or moral obsessions. Scrupulosity can sometimes be difficult to recognize because even within a single faith community, religious beliefs and practices vary widely. There is no singular belief or behavior that is diagnostic for scrupulosity.

Instead, scrupulosity is best regarded as a pattern of beliefs and behaviors associated with excessive worry about having committed a sin or engaging in immoral acts. Concern may focus either on thoughts or actions already taken or the possibility of committing sins in the future. This results in significant emotional distress, guilt, and despair.

Scrupulous individuals also worry about the sinfulness of having bad thoughts. This experience is very similar to individuals with OCD who experience harm-related obsessions (e.g., the fear of harming a child or loved one). People with scrupulosity often wonder why they’re having bad thoughts and worry that these thoughts have special meaning. They also mistakenly assume that they wouldn’t be having these thoughts if the thoughts weren’t true.

Because the sinfulness of thoughts is discussed in the Bible and other religious texts, many scrupulous individuals take this as “proof” that they should be able to control their thoughts at all times. For individuals who hold this belief, it is especially important that treatment includes steps related to belief clarification. Treatment of scrupulosity may also include consultations with religious professionals. When I treat individuals in South Florida (Palm Beach Gardens, West Palm Beach, Jupiter) with scrupulosity, I typically incorporate these elements in my treatment plan.

Feared consequences associated with scrupulosity often focus on damnation, estrangement from God, making God angry, or living an empty existence. There may also be the fear that one may “corrupt” others or experience uncontrollable feelings of guilt forever.

In order to prevent these outcomes from occurring, individuals with religious scrupulosity engage in a variety of rituals. These compulsions typically involve taking preventative action to keep a sin from occurring or engaging in some type of restoration ritual to repair their relationship with God. People with scrupulosity also commonly engage in a variety of mental rituals.

How is Scrupulosity Diagnosed?

Diagnosis of scrupulosity is complicated because symptoms of scrupulosity exist at the intersection of spirituality and mental health.  This results in symptoms of scrupulosity frequently going undetected. Psychologists may not sufficiently inquire about one’s faith tradition and overlook scrupulous symptoms.  Similarly, religious professionals may have less experience in recognizing signs of obsessive-compulsive disorder (OCD).  Parents of scrupulous children often take pride in their children’s seemingly strong faith and fail to recognize that their “faith” is predominantly fear-based. Because of these challenges, it is especially important to foster better public awareness about scrupulosity and how it relates to OCD.

Here are some common obsessions and compulsions associated with scrupulosity.  Because many of these behaviors are normal within certain faith traditions, it can be useful to consult with an OCD specialist if you’re concerned about these (or other) symptoms.

Symptoms of Scrupulosity (OCD)

• Fear of committing blasphemy or having blasphemous thoughts.
• Excessive fear of hell and/or damnation.
• Fear of committing (or having committed) an “unpardonable sin.”
• Excessive worry that one’s life is on the “wrong path.”
• Excessive concern about doing the “right thing.”
• Applying different moral standards to one’s own behavior than to the behavior of others.
• Excessive concern about clothing choices (i.e., not wanting to dress provocatively).
• Excessive concern about child-rearing practices.
• Afraid that one will (or has) sold one’s soul to the Devil.
• Afraid that one is secretly a Satanist.
• Intrusive images of sex or violence related to religious figures (God, Jesus, Mary, saints, etc.)
• Repetitive thoughts about being sexually attracted to God, Jesus, Mary, saints, or other religious figures.
• Intrusive images of inverted crosses, pentagrams, or other sacrilegious icons.
• Fear that one may secretly be possessed by demons.
• Fear that one’s children may be possessed by demons.
• Fear of future actions (e.g., worry that one will have to murder their children if they are possessed).
• Fear of being (or becoming) the Antichrist.
• Fear that one’s kids may be the Antichrist.
• Worry about whether one is fundamentally good or evil.
• Afraid of repeating prayers backwards.
• Fear of secretly wanting to go to hell.
• Fear of impulsively or intentionally praying to the Devil.
• Intrusive thoughts related to loving the Devil (e.g., Satan is Lord).
• Fear of secretly being controlled by the Devil and carrying out his wishes.
• Intrusive thoughts about rejecting the Holy Spirit.
• Intrusive thoughts about impulsively committing suicide and going to hell.

Compulsions Related to Scrupulosity (OCD)

• Repeating or restarting prayers.
• Praying excessively.
• Compulsively seeking out information online about the sinfulness of certain activities.
• Excessively attending confession.
• Compulsive reassurance-seeking from family members or members of one’s faith community.
• Did I do the right thing?
• Do you think it’s okay if I…?
• Compulsive self-reassurance
• Repeatedly saying: “I’m a good Christian person” after experiencing an unwanted thought.
• Repeatedly saying: “God loves me” after having an unwanted thought.
• Compulsive writing (e.g., Jesus loves me).
• Mentally reviewing or analyzing events to determine if a sin was committed.
• Taking religious practices to extremes.
• “Observing the Sabbath” in a way that’s not typical for others in one’s faith tradition.
• Fasting in a way that’s not typical for other members of one’s religious community.
• Engaging in self-punishing atonement practices that are not characteristic of one’s faith.
• Making deals with God.
• Planning and preparing for future religious problems (e.g., researching exorcisms).
• Replacing unwanted thoughts or images with safer or holier images.
• Thinking of images of the cross, doves, Jesus’s face, Mary’s face.
• Mentally inverting unwanted images.
• Inspecting one’s body for “signs” from God or the Devil.
• Examining birthmarks or looking for moles that indicate whether one is good or evil.
• Restarting or cleansing rituals.
• Getting out of bed again.
• Taking showers.
• “Renewing” oneself through mini-Baptisms.
• Asking for forgiveness excessively.
• Excessive study of religious texts (i.e., Bible, Torah, or Koran).

Avoidance Behaviors Related to Scrupulosity (OCD)

• Avoiding religious services (if one is afraid of God’s judgment for having bad thoughts while attending a service).
• Avoiding communion (if afraid of dropping a communion wafer).
• Avoiding triggers related to other spiritual or secular belief systems.
• Avoiding books, movies, or magazines that mention evolution.
• Avoiding yoga or other practices that developed out of a different faith tradition.
• Avoiding numbers that are unlucky or have religious significance (e.g., 13, 666).
• Avoiding reading the Bible, Torah, or Koran.
• Postponing decisions until they “feel right” or until God gives a clear sign about what to do.
• Avoiding prayer (if afraid of having a bad thought while praying).
• Deferring decisions to other people.
• Avoiding eye contact with members of the opposite sex (if afraid of committing adultery).

Remember, effective treatment for scrupulosity is based on exposure and ritual prevention, a type of behavioral therapy that was designed to treat obsessive-compulsive disorder (OCD). However, ERP will typically be augmented with steps related to belief clarification.

Questions? Comments? Do you experience scrupulous symptoms that were not mentioned above? Sound off below.

…or continue the discussion on Facebook, Twitter, or Google+.

Treatment of scrupulosity (religious/moral OCD) is based on exposure and response prevention (ERP), but pre-treatment goals often focus on belief clarification.

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 symptom of scrupulosity.

Treatment is then designed to help them develop a more functional and healthy relationship with God.

Once you’ve clarified your beliefs, the next step is to define appropriate treatment goals.

Moral/Religious OCD Treatment Goals

For anyone with scrupulosity/OCD, it’s unhelpful to define your goals in terms of impossibilities. You must set achievable treatment goals. For example, it would be unwise to select the goal of knowing for sure that you did the right thing or handled the situation the right way. Moreover, it would also be unhelpful to adopt the goal of trying to be 100% sure that God isn’t mad at you. For other people with scrupulosity, there may be the fear of hell/damnation and the unattainable goal of wanting to know 100% that you are saved. These types of goals just feed obsessive-compulsive symptoms.

No matter what we do, we can never know these things in the ways that OCD tells us we should know them. Perfect certainty about faith and morality just isn’t possible.

If you think about it, you’ll realize that these types of OCD-driven goals take faith completely out of religion.

Obsessive-compulsive disorder (OCD) often tells us that the only acceptable way to practice religion is to practice it with a perfect sense of knowing. This is actually incompatible with the idea that faith involves believing in something that can’t be seen or verified.

Appropriate treatment goals involve learning to live more comfortably in a world that is often gray, muddied, and confusing…to better tolerate OCD doubt, uncertainty, and ambiguity regarding our actions and intentions. This involves accepting yourself as an imperfect person who will inevitably mess up and learning to rely more on faith and less on certainty.

Exposure and Response Prevention (ERP) for Scrupulosity/OCD

Once you’ve set your goals, you then practice exposure and response prevention (ERP) for scrupulosity. You intentionally enter situations that trigger your doubt and uncertainty and resist the urge to escape or perform your rituals. For you, with the symptoms you’ve described, this would involve resisting the urge to cross-post religious topics on Facebook. Although this will feel dangerous at first, the more practice you get, the easier it will become.

There are also a variety of other exposures that might be helpful to you, such as thinking a bad thought on purpose. Again, this likely sounds dangerous if you’ve never done it before. However, after you’ve clarified your beliefs and defined appropriate treatment goals, you might determine that this territory is an important step in your recovery.

Would God understand and support your efforts to fight OCD?

Only you can answer this question.

Scrupulosity & Mental Rituals

It’s also important to note that when people have symptoms like yours, they often have a variety of mental rituals that accompany their obsessions. These include:

• Reviewing/re-analyzing/replaying scenes from the day to figure out if you did the “right” thing.
• Trying to figure out (i.e., questioning) your own motives in various situations.
• Compulsive praying (which often includes repeating/restarting prayers multiple times)
• Repeating prayers or restarting prayers if you get distracted or lose focus.
• Repeating prayers or restarting prayers if you are not concentrating 100% on the words of your prayer.
• Repeating prayers or restarting prayers if you had a bad thought during them.
• Repeating prayers or restarting prayers if you felt they weren’t 100% genuine.
• Reassurance-seeking behaviors.
• Asking others if you did the “right” thing.
• Excessively reading/studying religious texts (e.g., Bible/Torah/Koran) in order to inform current behavior.
• Asking for forgiveness excessively.

It’s important that you resist these rituals, as they will interfere with your progress in treatment. If you have a hard time determining if a certain behavior is problematic (e.g., praying, studying the Bible/Torah/Koran), it can be helpful to consult with a religious professional (e.g., pastor, priest, rabbi) in order to get feedback. Because not all clergy are familiar with OCD/scrupulosity, I would recommend that you have your therapist join you at this meeting.

After this consultation, it may be helpful to set parameters for your prayer. For example, you may decide to pray at specific times, limit the amount of time you spend praying, and resist urges to repeat/restart prayers. If these behaviors reflect symptoms of scrupulosity, they can actually interfere with being able to establish a healthy relationship with your religion.

Just like any form of OCD, scrupulosity can be effectively treated through exposure and response prevention (ERP). Given the complexity of these symptoms, I would recommend getting the assistance of a therapist who specializes in treating OCD. If you live in a remote area and there are no local providers, there are probably providers in your state who would be willing to do therapy by phone or over Skype. If you use a screen-sharing program, you could even do some of the Facebook exposures “together.”

Wishing you the best in your recovery from religious scrupulosity!

Questions? Comments? Experience with recovering from religious obsessive-compulsive disorder? Sound off below.

…or continue the discussion on Facebook, Twitter, or Google+.

Exposure & response prevention (ERP) is like an exercise program for your brain.

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, there is no one exposure that will help you get better. Instead, there is an array of options that might work for you. Develop your treatment plan deliberately and thoughtfully on the basis of your OCD symptoms.

Exposure therapy is based on a hierarchy that builds skills over time.

Physical exercise is hierarchical. If you want to get stronger, it’s smart to start with light weights and build up to heavier ones. It would be downright dangerous to attempt a 500lb bench press without proper training. In ERP, going for that “10″ on your hierarchy is ill-advised at the beginning of treatment. Before going there, you need to lay the proper groundwork first. A gradual approach might take more time, but it will get you to the destination without subjecting you to unnecessary injuries.

Like any exercise, ERP will make you “sore” at first.

If you’ve ever started a personal fitness program, you know that the first few days or weeks of a new routine can be downright painful. It’s common to feel aches and soreness in muscles that you didn’t even know you had. If you’re unaccustomed to exposure and non-avoidance, early exposures might feel especially challenging. However, like any exercise program, the soreness associated with exposure and response prevention will decrease with practice and give way to increased mental and behavioral flexibility.

Therapists, like trainers, have different styles.

Not everyone is a drill sergeant. The best trainers will listen to you, work with you, and try to understand where you’re coming from. They’ll then use their expertise to design an individualized plan for you that is based on your goals, preferences, and unique perspective. The best therapists I know follow this same approach to treatment. If you’re completing an exposure under duress, you’re unlikely to benefit from it. It’s the process of choosing to face your fear (and willingly embracing the uncertainty that comes with it) that leads to lasting recovery.

ERP is a personal journey.

Even the best trainer in the world can’t do the work for you. The success you will have in your therapy depends on the amount of time and effort you invest in the process. The right support system can be critical to your success, but ultimately there is no substitute for hard work. Own the process of treatment.

Progress in treatment requires consistent day-to-day effort in addition to your scheduled therapy sessions.

If you go to the gym only once a week, you will never look like a champion bodybuilder. Large investments of your time will result in significant gains, whereas small investments may yield little (if any) benefit. For you to reach your treatment goals, you must prioritize your recovery and keep exposure time from getting swallowed by life’s hectic pace. This means putting forth effort even when you don’t feel like it.

SSRIs can be helpful, but they are not a substitute for therapy.

Protein may fuel muscle growth, but it’s unlikely to yield any significant benefit if it doesn’t accompany behavioral changes like exercise. Similarly, “supplements” like SSRIs can be helpful, but you shouldn’t consider them a “magic bullet” that will eliminate your OCD with no effort on your part.

Treatment effects can generalize.

The squat is considered the “king” of lower body exercises, because it results in a flood of human growth hormone that can stimulate muscle development in other body areas. Exercises like squats have the potential to pay whole-body dividends. Similarly, solid exposure and non-avoidance skills transcend the specific symptom area you’re targeting. Once you understand the process of exposure and response prevention, you develop core skills that go beyond your immediate treatment goal and result in generalized improvement.

Exposure and response prevention (ERP) is based on human physiology.

If you visit your doctor and ask what you can do to build muscle and strength, he or she will recommend exercise. If you ask your doctor for alternative strategies for muscle development, he or she would be pretty hardpressed to come up with a list of effective alternatives. Exercise works because it’s based on human physiology. There’s no real substitute for exercise when it comes to muscle growth and development.

So, too, for exposure. Exposure is one of the only evidence-based treatments for OCD. Exposure and response prevention works because it capitalizes on human physiological processes like habituation. What causes ERP to fail sometimes? It’s often not ERP itself that fails but rather that the treatment wasn’t delivered in an effective way. For example, important factors might go overlooked when developing your treatment plan. This might cause you to select exposures that target the wrong “muscle” groups. Of course, other likely causes for treatment non-response are issues related to the consistency or form that exposures take. This is one of the reasons why it’s helpful to have a therapist oversee treatment and provide feedback.

Rituals are like junk food.

If you’re doing exposure in one moment and ritualizing the next, it’s a bit like going to McDonald’s after your workout. You might think you’re getting thinner, but you might actually be gaining weight. Rituals will sabotage your efforts. It’s important to adopt a philosophy of living that incorporates consistent response prevention.

Recovery is not an endpoint; it’s a lifestyle.

Although you might accomplish your specific goals related to fitness, in order to maintain the gains you’ve made, you need to figure out how to incorporate exercise in your daily life. The same principle is true for exposure.

Exposure therapy is not a strategy to be set aside after reaching your therapeutic goals. Instead, it’s a technique that you want to integrate into your day-to-day lifestyle. Moreover, just like exercise, there will likely be times when you’ll need to increase the frequency or intensity of your exposures. Just as many people up their exercise after the holidays, so too will you have to dial up your exposures during periods of stress or change.

Questions? Comments? What strategies do you use to maintain your fit brain?

…or continue the discussion on Facebook, Twitter, or Google+.

Unlike Choose Your Own Adventure books, therapy is a forgiving process that gives you many potential paths to pursue on your road to recovery.

“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 paths to pursue, all roads leading to the same basic ending: you taking your life back.

Pterodactyls beware. We’re coming for you.

Questions? Comments? What adventure will you choose today?

…or continue the discussion on Facebook, Twitter, or Google+.

If you insist on being symptom-free, “normal” body- and thought-noise become potential threats. This is because they are perceived as unwanted and dangerous.

Suppressing Unwanted Thoughts & Sensations in Pure-O & Sensorimotor OCD

Let’s explore this idea in detail. Suppose I adopt the goal of being 100% symptom free. After all, this is the endpoint of treatment that most people are seeking.

What are the implications of this goal?

You will likely slow down your progress.

Why? Because every day you will encounter something that violates your expectations.

Unwanted thoughts are a normal part of the human experience. Everyone has thoughts that are unwanted, aggressive, selfish, perverse, or deviant at times. For people without OCD, these thoughts tend to be fleeting because the thoughts themselves aren’t treated as significant. They are accepted as normal brain noise. These thoughts may register, but they quickly get buried beneath other more pressing or interesting thoughts.

For people with Pure-O OCD, unwanted thoughts may occur over and over again. Often these thoughts are considered dangerous or preventable, or they may be regarded as problems in need of solutions. Many people with Pure-O OCD become emotionally invested in filling their heads with the “right” kinds of thoughts.

It is largely the importance we attribute to our unwanted thoughts that determines whether or not they get stuck. As soon as we shift into problem-solving mode via a behavioral ritual or a mental compulsion, we increase the salience and power of the perceived threat.

Rituals reinforce and sustain what-if’s, which is why rituals are so good at maintaining OCD symptoms over many days, months, and years.

If you read my last post about thought control in OCD, you recognize that never having an unwanted thought is an impossible goal. Our brains just don’t work that way. If you insist on being symptom-free, “normal” body-noise and thought-noise becomes a potential threat. This is because it leads you to characterize something normal as unwanted and dangerous.

If you think about it, you’ll realize that it is often not the actual occurrence of symptoms themselves that creates anxiety, but rather the personal ramifications of those symptoms. For people with Pure-O OCD, fear is often based on the possibility that having an unwanted thought means something about you (e.g., maybe you secretly want to harm a family member or maybe you’re really gay). For people with sensorimotor OCD, fear is often based on the idea that you’ll notice unwanted sensations for the rest of your life and that these symptoms will prevent you from living the type of life you want.

Because of these fears, many people with Pure-O OCD (including sensorimotor OCD) adopt thought control as a means for managing, preventing, or reducing the impact of obsessions. Unfortunately, attempts at thought control and fear about a future dominated by symptoms often create a self-perpetuating cycle of fear and avoidance.

Unwanted Thoughts: OCD Feedback Loop

Because thought control is incompatible with the way our brains actually work, it is destined to fail. As soon as it fails and your unwanted thoughts return, your desperation and fear is likely to increase exponentially. This causes many people with Pure-O to re-double their efforts at thought control because they don’t see any other way out. Again, these efforts fail. After repeating this cycle multiple times, individuals often conclude that they are “doomed.”

Moreover, because individuals don’t want their current experience to be “tainted” by their symptoms, they frequently begin avoiding and isolating. They disengage from work responsibilities, stop dating, no longer go to the movies, quit playing golf, etc. Avoidance comes to pervade much of daily life. When avoidance is extreme, symptoms can become a person’s only companion.

Because our brains are constantly abuzz with noisy thoughts, we are guaranteed to notice something unwanted if we look hard enough. If we insist on being 100% symptom-free, it’s easy to become hypervigilant and more sensitized to potential threats. We then are primed to notice smaller and smaller deviations from what we consider “normal”.

As you are engaging in treatment and are getting better, how you handle breakthrough symptoms will largely determine your outcome. If you say, “Aha! It’s still here! I’m never going to escape this!” you turn up the volume on your symptoms. If instead you say, “I can do complex things, even if some of my attention is focused on my symptoms,” the volume is dialed down.

Recovery from OCD involves breaking this cycle by re-engaging in life. It involves treating breakthrough symptoms as normal and unavoidable.

In some ways, this is a very Acceptance & Commitment Therapy (ACT) based way of thinking about your symptoms.

OCD Treatment Goals

Back to the original question…what should be one’s ultimate treatment goal? It should not be to control your thinking. We all have unwanted or “unacceptable” thoughts at times. It is how we respond to these thoughts that either perpetuates them or allows them to drift elsewhere.

Instead, we should work on living according to our values and building the types of lives we want for ourselves despite our symptoms. In a way, embracing coexistence with the unwanted actually creates more space in ourselves for those things we truly want.

Questions? Comments? What have you adopted as your treatment goals? Share below.

…or continue the discussion on Facebook, Twitter, or Google+.

A penguin obsessed with flying is an unhappy penguin. Resist efforts to suppress unwanted thoughts.

OCD & Thought Control

Can I learn to eliminate my OCD thoughts?

I hear this question all the time from new patients who are searching for ways to suppress their unwanted thoughts. When I answer this question with a resounding “no”, there is often much surprise and grief. After all, this is why they’re coming to see me.

Many people with Pure-O OCD imagine thought control to be the only way to improve the quality of their lives. Unfortunately, thought control conceptualized in this way is not an attainable goal in OCD treatment. Our brains just don’t work like that.

I explain it like this, “A penguin obsessed with flying is an unhappy penguin.”

Expecting thought control to work is a little bit like a penguin flapping its wings and expecting to fly. It may work for the other birds, but it won’t work for the penguin. The penguin’s wings are not designed to work this way.

This doesn’t mean that penguins can’t be happy. It simply means that a penguin who becomes preoccupied with an unattainable goal is likely to experience a lot of unnecessary suffering.

Our brains are not equipped to simply ignore situations we perceive as threatening. If you were walking in the woods and noticed a snake slithering up next to you, your brain wouldn’t allow you to just ignore it. Instead, it would come up with solutions for surviving the situation. Fight-or-flight is biologically-based. Because survival is critical, our brains are hard-wired to act quickly and aggressively to guarantee it.

As much as you might wish to never have bad thoughts, you can’t change the way the human brain fundamentally works.

There is a solution, however.

It does not involve suppressing the thought or never having the thought in the first place.

Instead, it involves becoming less afraid of your thoughts and learning to correct any threat misappraisals to which you might be vulnerable.

If you’re a snake trainer, you have logged enough hours with snakes so that you’re much less afraid of them. You could even be around a whole nest of snakes and not break a sweat.

Exposure and response prevention for OCD is a bit like becoming a master snake trainer. Your fear won’t evaporate overnight, but with practice you will learn to be more comfortable and less distressed by your thoughts. You’ll also get better at tolerating doubt and uncertainty. This, in turn, makes the thoughts less newsworthy and thus less likely to stick to your sticky OCD brain.

Unwanted thoughts are normal. You can’t reprogram your brain to work in a way it wasn’t designed to work. Maybe someday when we’re all cyborgs, we’ll be able to delete the code in our brains that represents OCD-related fear. Until then, the next best thing for OCD is exposure and response prevention (ERP).

Questions? Comments? What is your opinion on thought control? Share below.

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