Obsessive Compulsive Disorder (OCD)
OCD is an anxiety disorder that often causes a great deal of doubt, shame, and suffering in one’s life. Due to the many types of obsessions and compulsions, OCD is frequently misdiagnosed and requires thorough assessment by a trained clinician.
Obsessions are defined as unwanted and uncontrollable thoughts, images, or urges that that trigger anxiety. The obsessions can be especially distressing because they tend to be linked to greater feared consequences (Ex: someone may have an obsession about getting or spreading an illness, and the overall fear consequence is dying or harming someone else by spreading the illness). Compulsions are the behaviors people engage in to reduce the anxiety. The compulsions only work short-term by creating limited relief, but actually strengthen OCD symptoms, as they become the way the person learns to cope with anxiety.
What are common obsessions: contamination or illness, harm to self or others, repeatedly thinking through the meaning of a thought or behavior, forgetting something or content of a conversation, loss of a person or a possession, misunderstanding someone else or being misunderstood, being imperfect, body image.
What are common compulsions: decontamination (hand washing, disinfecting), checking (doors, stove, body image or symptoms, others’ reactions), perfectionistic (need for symmetry, order), counting, touching, mental (rethinking, memorizing, repeating), over-responsibility (doing excessively more than others or being more accountable than others), hoarding.
How is OCD treated: The treatment that works for OCD is a type of Cognitive Behavior Therapy (CBT) called Exposure and Relapse Prevention (ERP). Medications are the second front line treatment for OCD, and often medications in combination with treatment offer the best outcomes. It is very helpful to add Acceptance and Commitment Therapy (ACT) to ERP to maximize the benefits of exposures.
How does Exposure and Response Prevention work: The exposure part of ERP involves gradually approaching the cues linked to obsessions (i.e., thoughts, images, situations, and objects). It is important to note that the exposure treatment is collaborative, always within the control of the client, and exposures are structured around what is important and matters to the client.
The response prevention part of ERP is gradually reducing or entirely avoiding the compulsion. The goal is to learn how to experience anxiety without safety behaviors, to learn how to get better at having anxiety.
How to tolerate uncertainty: Effective OCD treatment uses both exposure and response prevention, as well as learning to tolerate uncertainty by embracing the possibility of the ultimate feared consequence. The goal of exposure therapy in OCD is to create new learning that the feared situation is relatively safe and the anxiety is tolerable, even if it is possible that the ultimate fear does happen.
How do you do an exposure in ERP: an exposure for a person with contamination concerns may be spending time with loved ones (an exposure to the obsession of getting others sick, as well as an exposure to what is important to the person- family). They may sit nearby, not wash hands, share food, etc. (this style of approaching is the response prevention by reducing or removing the compulsion of avoidance). And while spending time with loved ones, they realize they may get sick, may get others sick, someone may even end up in a hospital (tolerate uncertainty).
Body Dysmorphic Disorder (BDD)
BDD is considered an Obsessive Compulsive spectrum disorder, as there are both obsessions and compulsions present. The obsessions in BDD are unwanted, and persistent and the compulsions reduce the anxiety from obsessions (only in the short-term) -just the same as in OCD.
Obsessions in BDD: The obsessions in BDD are more specifically related to the body (often obsessed about one’s perceived or actual flaws). People with BDD have been found to have more attention to detail and overly focus on details of the body, especially facial features.
Compulsions in BDD: The compulsions in BDD are frequently related to mirrors (avoiding mirrors and/or repeatedly checking mirrors, binocular like focus at an identified flaw when looking in the mirror). Other compulsions in BDD can include covering up the flaws or one’s body in general, attempting to appear more muscular, rituals with clothing (avoiding, frequently changing) and assurance seeking related to appearance. Panic attacks related to the body can also occur, and common times are during showers or in front of mirrors. Symptoms interfere in social and emotional functioning – often in the form of avoiding or withdrawing.
What is the difference between OCD and BDD: Though the disorders and the treatments are very similar, there are also differences. People with BDD can experience increased concerns in the following areas: self-esteem, depression, and suicidality.
Treatment for BDD: Cognitive Behavior Therapy (CBT) is the main treatment for BDD. Mindfulness, self-compassion, and Behavior Activation strategies are helpful along side CBT to reduce overall depression, anxiety, and low self-esteem that is often co-occurring with BPD.
CBT for BDD includes:
- ERP (facing fears while at the same time refraining from rituals – i.e., going to a social gathering and avoiding repeated mirror checking, going into a store without disguising a part of the body that brings distress, over time developing an average relationship with mirrors).
- Increase effective thinking (challenge distorted thoughts, increase mindfulness to thoughts, and participate in behavior experiments to confirm or disconfirm body image beliefs).
- Increase attentional control (learn non-judgmental and more holistic attention to oneself instead of narrow attention only on the flaw).
Panic Disorder
What are the first signs of a panic attack: A panic attack is an experience of intense fear and abrupt, short lasting changes in body symptoms. This may include any of the following: feeling short of breath, increased heart rate, sweating, and an urge to flee the situation you are in. Many can end up in the hospital believing they have a medical condition (such as a heart attack) but are actually experiencing panic. One can experience either a full blown panic attack (5 or more physical symptoms) or a limited symptom attack (with less symptoms than a full attack).
How long does a panic attack last: Panic attacks can last on average 5-20 minutes and generally less than an hour. Even if you do nothing about it, your body will have to return to a normal state before the panic attack.
How do you deal with recurrent panic attacks: A first panic attack is often a response to a stressor or anxiety. When people feel a loss of control or fear of the body symptoms and thoughts that occur in panic, they can have repeated panic attacks.
Repeated panic attacks is called Panic disorder and can lead to Agoraphobia, especially when untreated for a duration of time. Agoraphobia includes either extreme dread or complete avoidance of situations that an escape is either difficult or unavailable (going in public, stores, crowds, using public transportation).
How to treat Panic Disorder: Cognitive Behavior Therapy is the most evidence-based therapy for panic. This includes facing both cues in the environment that cause panic (in-vivo exposure) and body cues that are similar to panic (interoceptive exposure). Breathing and thinking skills are taught to use during and after exposure situations. The goal of the breathing, thinking, and exposure practices is to gain new learning that both the situations and the anxiety are relatively safe and can be tolerated.
Perfectionism
What does it mean to be perfectionistic: Having high standards can be very healthy. When assessing for perfectionism, it is important to distinguish between effective goal setting with high standards and perfectionism. A perfectionist sets unrealistic goals across areas of their life and commonly has extreme reactions to their perceived or actual failures (low sense of worth, judgments and self-criticisms, either avoiding or relentlessly persisting behaviors).
Treatment for Perfectionism: There can be a variety of approaches to reduce perfectionism. Cognitive Behavior Therapy teaches people how to practice high achieving or less than perfect behaviors, to challenge critical thinking, and to increase tolerance to imperfection.
Self-compassion therapy teaches mindfulness to reduce critical thinking, to offer oneself curious, kind, gentle, and accepting responses. Self-compassion helps one set realistic expectations and offer self-validation. Reducing perfectionism does not mean eliminating goals or standards. Self-compassion includes holding oneself accountable to goals and values.
More Anxiety Disorders
General Anxiety Disorder (GAD) includes persistent and unrealistic worry about the unknown (future, school, work, money, and others). The worry is often related to a realistic problem but is experienced in an extreme way, as it can interfere in sleep, concentration, relationships, and life. When people experience a baseline of anxiety, their body is typically tense and fatigued, and they are commonly avoidant of any anxious situations, which can commonly lead to depression.
Social Anxiety Disorder (SAD) includes worry specifically related to being around others. There may be extreme fears of embarrassment or humiliation around others and often avoidant behavior in social situations (avoiding eye contact, hanging back, worrying about perceptions of others).
Specific Phobias are fears that are persistent and/or the fear disrupts the person’s life. Common types of phobias can be dogs, spiders, blood, heights, small rooms or spaces.
The treatment for GAD, SAD, and Phobias is Cognitive Behavior Therapy (CBT). Anxiety management skills include the following: breathing skills to regulate the tense body and thinking skills to activate more factual thinking about the likelihood of worries, as well as the ability to cope with worries happening. Often Imaginal Exposure can be used in session to vividly call to mind a worry situation and get coaching on how to manage the anxiety.
Behavior Activation Therapy is another type of treatment that can be useful. It has been considered a form of CBT and helps change unwanted behaviors by creating a list of avoided situations that would be helpful to gradually approach, as well as a list of behaviors that would increase a sense of mastery and build pleasant emotions. This approach helps reduce depression and anxiety.