Breaking free from OCD

Obsessive-compulsive disorder (OCD) features a pattern of unwanted thoughts and fears known as obsessions. These obsessions lead you to do repetitive behaviors, also called compulsions. These obsessions and compulsions get in the way of daily activities and cause a lot of distress.

(https://www.mayoclinic.org/diseases-conditions/obsessive-compulsive-disorder/symptoms-causes/syc-20354432?utm_source=Google&utm_medium=abstract&utm_content=Obsessive-compulsive-==&utm_campaign=Knowledge-panel)

OCD can turn any fear into an obsession but structurally, the same pattern persists throughout:

Obsession --> Attached Meaning --> Compulsions --> Relief

Obsession:

People with OCD experience unwanted, unwelcome (intrusive) thoughts, images, feelings or sensations that cause significant distress. These are referred to as ego-dystonic as they do not align with the person's wishes, wants, or values and are commonly scary, dark, or upsetting. These obsessions are activated by triggers, or internal or external cues associated with the fear.

Example: Sarah, 24, is a preschool teacher in an allergy-safe classroom. One day a student with a a nut allergy has an allergic reaction which is resolved with a trip to the nurse, some antihistamine medication, and rest at home. It is eventually determined the student ate something from home they did not realize was made with nuts. The experience is deeply distressing for Sarah, and she begins to ruminate on it.

Attached meaning: Understandably, people with OCD at first feel confused and scared by intrusive experiences, and attach personalized meaning to them, fearing they reflect some deeper flaw, and often reporting an almost moral obligation to dwell on them or figure them out.

Example: Sarah worked extremely hard to achieve her dream of being a teacher. She loves her job, loves the kids, and feels proud that she is trusted to care for them. She would never forgive herself if something bad happened.  

Compulsions:

This "figuring out" takes various but ultimately predictable forms. Compulsions can by physical or mental. They are ritualized and repetitive. They may have some logical connection to the fear or they may not. Compulsions often feel urgent, demanding, and all-consuming. At their core, compulsions are a form of avoidance.

Some commonly seen compulsions include: knocking on wood, hand-washing, "cancelling out" negative thought content with positive content, confessing fears to loved ones, reassuring oneself or seeking reassurance from others, excessive research, investigating "what-if's", replaying scenarios, and mentally rehearsing possible future feared scenarios.

Compulsions are often fueled by a desire to make sure, beyond a shadow of the doubt, that it is safe to let go of the worry. *The trick here is letting go of the worry is what allows for a return to emotional safety.

Example: Sarah starts reading the ingredient labels on the snacks students bring from home 3 times. She figures that is sufficient to make sure she didn't miss anything. If she is interrupted in her 3 time review, she starts over. 

She imagines the student having another reaction, the outcome being much worse, and the public outcry that would surely follow. She thinks of the times she was not so careful, and imagines what might have happened. 

She remembers stories of other tragedies in classrooms and spends hours researching the details, considering how likely such an event is to occur to her as well as various safeguards she could put into place. 

Sarah feels ashamed of the amount of time she is preoccupied by this fear. She often feels distracted and unable to be fully present with her students as she performs her various compulsions. She even starts to think about quitting, the worry feels unmanageable and she wonders if she should be in the trusted role of teacher at all. 

Relief:

Compulsions over temporary relief from fear in that they provide a distraction from the uncomfortable feelings associated with it. However when the fear inevitably returns, the person has not developed any better relationship with the feelings, and instead feels the only way to cope is to once again turn to compulsions.

Example:

Example: Sarah feels a sense of relief every time she finished reading the ingredient labels on the student's snacks from home. It's time consuming but so-far nothing has slipped through so why stop now? Isn't the safety of her students worth a double, or triple check? 

BREAKING THE CYCLE:

The path out of the OCD trap is to release compulsions, and allow for kind and compassionate direct experiencing. That means acknowledging the fear, accepting the uncertainty, and allowing the feelings space to move through the body.

Exposure and Response Therapy (ERP) works be inviting the client to turn toward the distress signal, invite in challenging feelings, and practice resisting or disengaging from compulsions which prevent the feelings from running their course. It is a mindfulness skill that is easily acquired and practiced and highly effective in restoring emotional health. (More on this in another blog post).

Example: 

Of course Sarah should take all reasonable efforts to protect the students in her classroom from foreseeable harm, but that does not change the reality that bad things sometimes happen. 

In order to break the addictive cycle of OCD, Sarah needs to practice resisting her compulsions and making space for the emotions attached to the fear of uncertainty. Instead of reading the ingredient list 3 times, Sarah should go down to 1, or down to 2, then 1. She should decide with her rational brain what is reasonable, and stick to it despite the expected distress. 

Sarah can reminder herself "no matter how many times I read these labels, it is possible that I might miss a concerning ingredient". As upsetting as this sentence might sound, it is true and there is immense relief in acknowledging our the reality of our limitations.

Resisting compulsions and allowing for feelings of distress around uncertainty does several things:

1. It builds emotional resilience. Instead of hitting the escape button on her distress, Sarah is allowing herself to feel uncomfortable. Emotions, when allowed, expand and collapse very quickly. We just need to get out of the way. 

2. It empowers Sarah to assume agency and exercise free will. Sarah gets to decide how to proceed in the landscape of risk and fear, not some rule book she doesn't really agree with. 

3. It allows for a corrective emotional experience. In disrupting the compulsion, the stage is set for new learning in a landscape that mindfully acknowledges uncertainty.