Dr. Moses Appel (edited by Matthew Shields)
As if struck by lightning, Zachary halts in his tracks while New York City foot traffic swarms around him. He presses the sides of his temple with his thumb and pinkie, wondering, Did I turn off the stove before I left my apartment? He pulls out his phone from his pocket – 8:33 a.m. - right on time to make it to his job interview at Deloitte, his dream accounting firm. Zachary knows that if he returns to his apartment to check on his stove burners, someone else gets the offer. But the thought of potentially igniting the entire apartment complex leaves him gasping for breath, and even worse, feeling consumed by self-hatred.
Once again, Zachary is stuck in an obsession he knows all too well.
What is OCD?
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM), to be defined as having Obsessive-compulsive disorder (OCD), a person must meet the following criteria. First, they must experience Obsessions or Compulsions (usually they have both); and second, their OCD symptoms must last for more than an hour each day or cause clinically significant distress or result in functional impairment. There are many types of OCD, including Contamination OCD (fear of germs or feelings of disgust), Relationship OCD, Scrupulosity/Religious OCD, “Just right” OCD, and “Pure O” (as in purely obsessional – although usually this type is accompanied by mental compulsions), just to list a few. Zachary happens to experience the disorder as a mixture of two other types of OCD, called Harm OCD and Checking OCD respectively, but the focus of this post is to introduce OCD overall.
An Explanation of Both Criteria Necessary for OCD:
Obsessions and Compulsions
Obsessions- Obsessions are recurrent thoughts, urges, or images that are intrusive and cause a person with OCD significant distress.
Zachary’s obsessions manifest with images of him lighting his apartment ablaze. Some days, he watches his prized possessions – the watch his grandfather gave him on the day he graduated from middle school; his diplomas and awards in Accounting from college; the tefillin (leather straps worn during prayer) that he’s worn every day since he was thirteen – become lost forever. Those are the good days. On other days, he vividly pictures himself and his neighbors losing their lives due to his mistake.
Compulsions are behaviors or thoughts that one engages in to temporarily relieve the distress caused by the obsession.
For Zachary, this means going through the arduous task of moving his oven, checking the gas line, constantly touching the stove, devoting dozens of hours each year to fire safety, and spending $75 a month on a state-of-the-art fire extinguisher. He also spends an inordinate amount of time trying to battle the mental images of what may happen if he’s had a lapse in judgment and left the stove on.
The degree to which OCD impacts day-to-day life.
For years now, Zachary has spent every single day envisaging these scenarios. These visions don’t necessarily occur sequentially for him, but they cause him tremendous suffering. While on the surface it might seem that Zachary’s compulsion to check the stove is both responsible and effective in treating his OCD, this is unfortunately not the case. When the visions of fire first started, Zachary could abate his obsession by checking the stove two or three times a day. Now, however, he needs to feel the burners hundreds of times a day to feel some sort of relief. Compulsions may alleviate stress in the present, but like drug addiction, the problem only gets harder to manage as time goes on.
Treatment Approach:
While different forms of OCD present with different “flavors," the treatment is generally the same (with few exceptions – such as in Sensorimotor OCD). The gold standard treatment for OCD is called Exposure and Response Prevention (ERP), sometimes referred to as ‘ritual prevention.’ This therapy is a form of Cognitive Behavior Therapy (CBT). Essentially, the treatment involves response prevention and exposures. Usually, a therapist will have a patient focus on response prevention and then begin initiating exposures.
What Are Response Prevention and Exposures in ERP?
Response prevention is just what it sounds like: not responding to the obsession.
For Zachary, his therapist decides that he can only check the stove one time a day. For all other times Zachary’s worried about the burners, he’s not allowed to check on the heating elements.
For someone with Contamination OCD, a therapist might instruct the patient to stop carrying hand sanitizer on the subway.
Exposures are deliberate attempts to induce obsessional anxiety to work on breaking the Obsession/Compulsion loop.
After working with his therapist to stop physically responding to his anxiety, Zachary is assigned homework: turn on the stove for 20 minutes each day. After a few weeks, Zachary’s therapist increases the challenge: ignite the stove, then leave the room. Then, Zachary’s therapist instructs him to turn on the stove and leave the apartment for a few minutes a day. At the end of each week, Zachary and his therapist discuss how that week’s ERP went. This pattern goes on for a few months, and Zachary really starts to see results.
How Do Exposures Work?
There are two main explanations for how exposures work: habituation and inhibitory learning. In the habituation model, the goal of exposures is to reduce the fear response through repeated exposure to the feared stimulus until the fear is no longer triggered. In the inhibitory learning model, the goal of the exposures is to engender new associations with the feared stimulus instead of merely habituating to it. According to this model, the original fear associations are still extant, but through repeated exposures, the patient develops new safety-based (inhibitory) associations to the fear. Thus, as per the theory underlying this model, when the patient is presented with the initially feared stimulus, the recently learned safety-association is activated instead of the initial fear response association, which has not been abolished but lies dormant. This model has practical implications for how exposure therapy is conducted. As long as the patient learns that the distress he or she experiences is tolerable, a new, safety-oriented association with the fear can be made. This shift in focus can be significant in exposure work because many patients find that solely focusing on reducing anxiety through habituation feels ineffective, and sometimes even causes them to become more anxious when they see that their anxiety level isn’t diminishing. Thus, shifting the focus from habituation to tolerance can be very helpful when practicing exposure therapy.
What’s the Goal of ERP?
Initially, patients with OCD will feel discomfort when employing the dual techniques of Response Prevention and Exposures. How could they not? There’s a reason they developed compulsions in the first place. Eventually, though, the more they practice ERP, the more they’ll habituate and feel less anxiety and/or learn to tolerate their anxiety and continue living their lives. Think of it like jumping into a cold pool on a hot summer day; at first, the cold water will be shocking, but over time, the person will get used to the water, barely even feeling that it’s cold anymore. ERP can also demonstrate to the patient that it’s possible to live an enjoyable and fulfilling life even while their anxieties are present.
Conclusion:
Obsessive-Compulsive Disorder is a very challenging and distressing mental health condition. People affected by OCD are confronted with irrational, but highly persuasive, fears and doubts. They use compulsions to try and relieve these thoughts and feelings, but in the long term this response only magnifies the problem, and worse, causes them more pain. The gold standard treatment for OCD is Exposure and Response Prevention (ERP), where, with the guidance of a therapist, the client resists the urge to act on their urges. Over time, they habituate to their fears or at least learn how to tolerate them, and the obsession loses a lot of its bite.
Thankfully, Zachary realized that he needed help managing his OCD months before his interview at Deloitte. He assures himself that it is ok to be afraid, but that he’s going to push through the discomfort and focus on the interview. At a board meeting the next week, the managing partner introduces his team to Zachary, the new associate.
Disclaimer: The character “Zachary” in this post is entirely fictional. This content is intended for informational purposes only and is not a substitute for professional therapy or treatment from a licensed mental health provider. To contact Dr. Appel, please email office@ADOPsychologyCenter.com.