Obsessive-Compulsive Disorder: Fighting Back

A young executive can't wear clothes until they are put on "just right." He loses his job because it takes him so many hours to get dressed.
A new mother is terrified that her blasphemous thoughts will kill her infant. So she stands over his crib repeating, "I love you Jesus" six times. If she's distracted by a thought of the Devil or the sound of a passing car outside, she starts again. And again.
A football coach is afraid that his favorite aunt will die in a car crash if he does something wrong-but "wrong" keeps changing so he has to stay on his toes. One day "wrong" means thinking of her as he puts on his favorite Lions jersey; the next day it means picking up a box of cereal at the grocery store with an "expires by…" date that adds up to his aunt's birthday.
No wonder Obsessive Compulsive Disorder is called the "doubting disease." Your obsessive thoughts cause your anxiety to soar. You try to calm yourself by doing rituals that make no sense to you intellectually. Still you shudder at the thought that if you don’t do what the OCD is telling you to do, something will go wrong-someone you love will be hurt, your day will be ruined. There will be dire consequences to someone, somewhere.

No matter how smart, logical, or compassionate you are, you are blackmailed by the thought, however irrational, that the OCD may be telling the truth and the stakes are too high to ignore it.

"My house could burn down if I don’t check the burners and knobs on the stove for half an hour," you think to yourself. "Really, how can I resist the time and effort involved in my rituals if there’s the slightest chance they really will protect my loved ones or me?"

Yet you’ve had enough of being blackmailed by your OCD. You want your life back.

After great thought, you decide to take on your OCD and go through the painful, exhilarating process of gaining mastery over your symptoms. You understand that you may never be entirely free of your obsessive thoughts, that you may find, in periods of stress, that your OCD regains some strength. But you know you can minimize its place in your life overall.

You’ve found a therapist who specializes in the treatment of choice for OCD: cognitive-behavioral therapy, or CBT. She tells you she’s going to work with you using a specific

kind of CBT with yet another set of initials, called exposure and ritual prevention, or E/RP.

"Your mind and body have been held hostage by your OCD symptoms but you can choose to fight back," she explains. "You can break the connection between your anxiety-producing obsessions and the irrational rituals meant to eliminate them. Then you can see, first-hand, that nothing bad happens."

"But I’ve tried to fight back a million times," you reply. "I always end up back in the throes of my OCD."

"I’m sure you’ve tried hard to fight your OCD," your therapist agrees. "We’re going to use that motivation of yours and help it along with a structured, systematic program that will allow you to confront your fears without ritualizing.

"In the past, your battle against the OCD has been like that of a would-be swimmer who jumps in a pool, finds the water freezing, and jumps out. He tries again every week, but always climbs out quickly, feeling too cold," she says.

"But now imagine that he decides he’s going to stay in the water until he can stand the cold. With some new mental weapons to handle it, he manages to stay in the pool for an hour at a time. As the minutes pass, he begins to adjust to the temperature. He repeats the exercise several times that day and then every day for the next month. Over time it gets easier; eventually he dismisses his initial "cold" thoughts because he knows he’ll stop noticing them shortly. He no longer avoids the water, and when he’s in it, he learns he can handle the cold. That could be you with your OCD."

MAPPING OCD’S ROLE IN YOUR LIFE
To start, you and your therapist do a comprehensive assessment, covering your history and other relevant concerns. You both agree you’re ready to start tackling your OCD so you examine your symptoms today. You say you worry about harming others, and it shows up in a variety of checking symptoms.

"I’m afraid I’ll run people over with my car, and at home I’m afraid I’ll burn my house down by leaving an appliance or the lights on, or get us robbed by forgetting to lock the doors or windows," you tell your therapist. "Every time I drive past a pedestrian, I look back for a body. When I get home, I ask my wife repeatedly to tell me that I couldn’t have hit anyone without knowing it. I keep checking the locks, the stove burners, the lights, the electric blanket in the winter and the fans in the summer. It’s exhausting-and it makes me feel crazy."

Your therapist gives you your first assignment. "Over the next week, play detective. Look at your life as though a video camera were following you around. Record on a sheet all of your obsessive worries and notice exactly what you do in an attempt to make them go away."

"It’s even worse than I’d thought," you tell her when you return the next week. "I realized that when I’m driving past someone, I listen for the thump of a body going under the wheel or a scream of pain. When I get out of the car, I even pass my hand over the body of the car to feel for new dents or skin or hair from someone I hit. Then I switch on the news at home to check for any reports of hit-and-run accidents where I drove."

"Those were behaviors aimed at neutralizing the anxiety caused by the obsessive fear of hitting someone," she explains. "Did you notice any situations or thoughts you avoided so you wouldn’t even trigger your OCD?," she asks.

"You bet. I realized that I drive blocks out of my way in the morning so I won’t pass elementary school kids walking to school," you say. In the process of stepping back and watching your OCD manipulate you, you discover obsessive thoughts, rituals and avoidance behaviors that have become so habitual that you’ve stopped noticing them. "My OCD controls me even more than I realized," you say flatly.

USING YOUR MIND AS A WEAPON AGAINST THE OCD
"You’ve really been bullied by your OCD, haven’t you?," says your therapist. "Of course, everybody has bad thoughts-‘What if I drop my infant down the stairs?’; ‘Did I turn the oven off when I left home?" What makes it hard for you is how long you spend worrying and trying to drive the demons away, and how much that affects your life. Most people let those bad thoughts go: they delete them like spam from their computer or junk mail in their mail box. For you, the thoughts are sticky: they won’t let go. The OCD convinces you that your rituals will make the bad feelings go away-they’ll make things right, or keep you or someone you love safe--so you keep doing them."

"That’s right," you reply. "It’s like a triple whammy. I’m upset by these disturbing thoughts and I’m mad at myself for taking them seriously, but I’m afraid to skip the ritual just in case it really works. Then I’m frustrated with myself for doing things that make so little sense!"

"The problem is that OCD is like a hungry, barking dog," she comments. "When you do your ritual to make the bad feelings go away, it’s like you feed the dog a steak to get it to leave you alone. Instead it just gets bigger and louder and looks tougher and more insatiable. You feel like you better feed it bigger and juicer steaks, more and more often, to keep it from harming you.

"I’ve noticed that," you exclaim. "I used to check my rear view mirror once, and now I need to check it three times to get any relief and even that doesn’t last. A year ago, when I got home, my wife just had to reassure me once that I couldn’t have hit anyone. Now I go back to her a half-dozen times throughout the evening for that reassurance. I keep needing more to keep the fears at bay. I feel like a drug addict."

"Well," she replies, "you’ve come in for treatment beccause you’ve decided to stop feeding the dog steak: no more rituals to make your obsessive thoughts go away and no more avoiding situations that might trigger those thoughts. You’re going to be doing something very different by standing up to that snarling dog. You’ll discover that it’s bluffing; it’s really a pussy cat who can’t hurt you. You’re going to label the OCD for what it is: an irrational belief that your rituals offer protection against those awful thoughts."

You ponder that. "I can see an OCD obsession as a hungry dog that I just make more greedy by feeding with my rituals. And you know what? I can also see it as an annoying mosquito bite. If I accept the itch and refuse to give in and scratch it, the itch eventually goes away. If I scratch it, it gets better at first. But then it gets worse and I just need to keep scratching more and more."

"Exactly," she replies. "I like that."

PLANNING YOUR TREATMENT STRATEGY
You discuss with your therapist whether to combine medication with the cognitive-behavioral therapy. She explains that a psychiatrist could consult with you about medication; one kind of antidepressant called SSRIs have been found to help about half of all people with OCD. "They help the most when they’re combined with CBT. But most people find their OCD symptoms return when they stop taking the medications so an SSRI alone isn’t enough, even if it works for you. Therapy is the best tool for long-term change. Many people benefit from combining CBT and medication. It’s up to you whether you want to use both," she says.

"Let me think about it," you reply. "I’ll probably schedule an evaluation with a psychiatrist and then consider the options."

You and your therapist then begin preparations for the exposure and ritual prevention program. Already you have your notes from your own detective work.Together you create a detailed inventory of all your obsessive thoughts, rituals and avoidance behaviors. Then you rank your compulsions by the degree of distress it causes you to experience the obsession and imagine not doing the desired ritual.

From easiest to hardest you list "hit-and-run" driving compulsions, followed by checking lights and various appliances, and finally checking doors and windows.You have many subtle distinctions for each category.

"In the car, I have the least anxiety when I’m driving on a deserted country road," you report. "My anxiety gets progressively worse driving on the highway, in a neighborhood, driving near a school, driving at rush hour and finally driving through a crowd, like before and after University of Michigan football games. I also realized I get more anxious when I’m tired, rushed, or stressed because of something like a fight with my wife or a stupid assignment from my boss."

You and your therapist design your first E/RP assignment. "You want to target a situation you really want to change," she says. That will motivate you to do the hard work E/RP demands of you. But you don’t want to pick something so overwhelming that you aren’t willing to do it."

"I want to start with driving," you reply. Together you make a plan that will be hard-but not too hard. "Let’s see if I have this down," you say. "The first week I’ll drive an hour a day on the highway in the right lane, looking for opportunities to drive near cars or people on the side of the road. I won’t use my "safety crutches" like looking in my rear-view mirror for bodies after passing someone, checking for dents when I leave the car, or asking my wife to tell me I didn’t hit anyone."

Also, you increase your anxiety by adding exposure to your bad thoughts. You place sticky-notes all over the dash board. They read: "I hit someone." "There’s blood on my grill." "I killed someone." You agree that you won’t stop doing the assignment each day until you feel less anxious than when you started.You promise to record your anxiety and success for each E/RP session on a form.

You’ve scheduled a double session with your therapist today so that when you finish your planning, you can go out in the car together. "In this therapist-assisted E/RP, I can help you practice the work you’ll be doing on your own," she says, as you walk together to your car. "We’ll do something just a little harder than your assignment while I’m here to give you support. That will make your daily homework less daunting."

For the next hour, she sits beside you while you drive on the highway, changing lanes repeatedly to increase your anxiety about hitting someone and then not looking in your mirrors to check. Your anxiety spikes at first but diminishes over the hour, and you head home confidently to begin your own E/RP.

As arranged, you call your therapist after three days of assignments to report on your progress and to see if you need to adjust the homework to help you succeed. "It was easier than I expected, but I still glanced back in the mirror several times each day. And I asked my wife for reassurance a few times when I got home," you acknowledge.

"That’s good information," says your therapist. "Continue the exposure but really put the brakes on seeking reassurance. How about adjusting the mirrors at a slightly awkward angle--just enough to interrupt your reflexive checking? And work hard not to ask your wife for reassurance. How about if we invite her in to the next session so she can learn better how to help?"

At the next appointment, you and your wife discuss the impact of your OCD on you and the family. You and your therapist give your wife a summary of all you know about OCD and its treatment.

"I understand that you reassure him so he’ll feel better," your therapist tells your wife. "It may feel awkward at first, but the best way to help is to let him experience the anxiety that comes with exposing himself to his fears. That way he learns that he can handle them and that his fears are unlikely to come true." She helps you and your wife find some possible new lines: "It sounds like your OCD is really getting to you;" "Those old OCD thoughts are getting stuck again," or "It’s hard to resist but you’re really trying." She adds: "You might feel badly for him, or even get impatient for him to get better faster, but it’s up to him. You don’t need to be his therapist. All you can do is encourage him and step back."

When your wife leaves, you and your therapist modify your assignment to improve your compliance. "OK. I’ll laminate little post-it notes with the words, "It’s not me, it’s my OCD" and tape them to my car’s rear view and side mirrors to make me more conscious of not checking them," you say. You also re-commit to zero tolerance of rituals or avoiding situations that bring up your obsessive thoughts.You’re more successful this time, and when your anxiety diminishes with this task, you’re ready to add a harder assignment that you craft with your therapist.

"Next I’m going to drive at least an hour a day in areas where I’ll probably see pedestrians on the road," you summarize at the end of the next session. "I’m scheduling trips past schools at 8 a.m. and 3 p.m. and past crowds before and after basketball games. When the anxiety goes down with this assignment, I’ll move up the list to a more challenging task: driving at dusk, when it’s harder to see pedestrians and I get more anxious."

Within a month you are driving places you hadn’t imagined possible without depending on your checking rituals.You’re proud and feeling increasingly optimistic about your ability to control your OCD. But you want to make sure this isn’t false confidence.

"I wonder if I’m calmer because I’m avoiding those scary thoughts that make me want to check and get reassured," you tell your therapist. "I know a way to find out," she says. So you add another layer of homework: mental exposure to the feared thoughts. She helps you write and then tape-record a script about a worse-case hit-and-run scenario.

You read it to her: "I hit a bump. I’ve run over a body. I hear a police siren. They’re coming for me. I’m sweating as I pull over on the next block. I check the grill on my car: I see skin, and can smell blood. I turn on the radio; already they’re reporting my hit-in-run. I’m sure I’ll go to prison." The story goes on.

You commit to spending an hour a day with twenty minutes each of reading the script, writing it out and listening to it. At first your anxiety spikes, but over time it becomes almost boring ("This is ridiculous: that just wouldn’t happen!," you think.). Eventually you can drop it from your daily E/RP tasks.

Now you’re significantly less anxious during and after each trip out. Over the months you continue moving up the hierarchy to increasingly difficult tasks and mastering them. Still, your progress is uneven, depending on how stressful your life is and other occasional bumps.

"Sometimes I want to quit," you admit to your therapist at a session. "I’m so much better and sometimes I think I’d rather just accept my progress and make life easier by giving in to a few rituals when I’m having a bad day."

"I understand," she says. "Standing up to your OCD can be exhausting. And yet if you feed that hungry dog an occasional steak, do you think that would satisfy it?"

"No," you reply. "And honestly, that’s what keeps me going when I’m tempted to take a break. That insatiable dog will always want more and I’m done being held hostage by it. I’ve gone cold turkey on my rituals and I’m committed to staying with this, but I’m going to need help."

Together you fine-tune your treatment plan to help you maintain your momentum and get the support you need. Your success motivates you and you continue to gain mastery over your OCD. The work is challenging and time-consuming and you know you still have more work ahead of you. But your courage is bringing you a reward that is life changing and indescribably sweet.

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To protect confidentiality, case descriptions in this article are based on composite or fictionalized clients.

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