ERP Tip of the Day #2

Posted by Steven J. Seay, Ph.D. in “Pure-O” Symptoms, CBT, Checking-Related Symptoms, Contamination/Health-Related Symptoms, ERP, ERP Tips, Harm-Related Symptoms, Obsessive-compulsive disorder (OCD), OCD, OCD - Treatment, Sexual Symptoms 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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ERP Tip of the Day #1

Posted by Steven J. Seay, Ph.D. in “Pure-O” Symptoms, CBT, Checking-Related Symptoms, ERP, ERP Tips, Harm-Related Symptoms, Obsessive-compulsive disorder (OCD), OCD, OCD - Treatment, Sexual Symptoms 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

Posted by Steven J. Seay, Ph.D. in “Pure-O” Symptoms, CBT, Checking-Related Symptoms, Contamination/Health-Related Symptoms, ERP, Harm-Related Symptoms, Obsessive-compulsive disorder (OCD), OCD, OCD - Treatment, Sexual Symptoms 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

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

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