By: Gedaliah Aronson
The basic formula for OCD (Obsessive Compulsive Disorder) is the same no matter how the disorder manifests itself in each individual. OCD has been labeled over the years as “the doubting disorder.” It is important to understand that all OCD sufferers are involved in a very intense battle with uncertainty. There is nothing in life anyone can be sure of with 100% certainty; there is always room for doubt no matter how small. Even if we can be 99% sure of something, there is still a 1% window of doubt. That small portion of doubt can be focused on, amplified, and therefore inflated to appear as though it is actually incredibly larger than it is. If we were to look at that doubt “particle” under a microscope it would no longer appear small or insignificant. I believe this can be used as an analogy to describe, in some way, what is happening emotionally in the midst of obsessing. Sufferers of OCD are very familiar with the question “what if…?” and have an amazing ability to delve deeply into that question. OCD requires a great deal of creativity and an ability to imagine what it might be like in “what if” scenarios to the point of actually feeling as though one is within the scenario.
This comes with much pressure, stress, anxiety and overall discomfort. It should be pointed out that this is not something that an OCD sufferer engages in willingly because they enjoy doing it. OCD is an exhausting and painful disorder and among the factors involved are biology and brain chemistry. In fact, the distinctive brain activity of OCD sufferers can be seen in a PET-Scan. There have even been cases where OCD sufferers, not yet aware that they had OCD, have gone to see neurologists for fear that they were suffering from serious physicals problems within the brain. In at least one situation a neurologist was familiar enough with the characteristics of the brain activity associated with OCD that he was able to lead the person in the direction of proper treatment for the disorder.
Dr. Jonathan Grayson points out in his book, “Freedom from Obsessive Compulsive Disorder,” that OCD sufferers have an ability to suspend their own realities and imagine what something might be like in various situations. This is often why OCD sufferers make good listeners, and are frequently the ones that friends choose to seek out to talk about difficulties, because the same quality that can make an obsession feel exceedingly real and tremendously scary is also the quality that allows them to place themselves in the shoes of a friend in need.
In the process of OCD a person experiences a “trigger” or “spike” which is a thought involving a word, phrase, idea, situation or scenario that is bothersome and intrusive. The intrusive part of the thought is the doubt and uncertainty present within it, i.e., the unwanted and therefore very scary possibilities implied, “if that’s true then that could mean…” Here an obsession cycle begins because the possibilities are endless. Sometimes the cycle of doubt can begin with the question, “why did I have that thought and what does it imply about me?” After much focus, attention and rumination, all of which happen incredibly fast, the doubt is magnified on an emotional level as if it were being viewed under a microscope.
To better understand this we can take an example from something we experience everyday. We cannot be 100% percent sure that the roof above our heads will not collapse as we sit under it, so why do we risk our lives everyday by going into buildings or living in our homes? We accept, with very reasonable evidence, that although we cannot be 100% certain of such an occurrence, the possibility is slight enough that we can feel safe in taking such a “chance.” This is an example of uncertainty tolerance and we all accept uncertainty to some degree or we would never be able to do anything in life; we would be frozen still. If there is a realistic possibility and certainly a probability of hazard, we would take the necessary precautions to protect ourselves and others. If we had enough evidence that a certain building was unsafe and should not be entered because it would be a realistic risk to do so, we would not enter and we would publicize the problem to protect others until the hazards could be eliminated.
Within the context of an obsession there is, in the emotional realm, very terrifying “evidence of hazard.” The OCD sufferer takes measures to remove the doubt, uncertainty and anxiety and these measures are called rituals. This is true with regard to the many manifestations of the disorder including contamination obsessions and rituals (like hand washing), “Inflated Responsibility” OCD,” and what is sometimes called “Pure-Obsessional” OCD, where both the obsessions and rituals take place cognitively without overt physical action.
A fascinating factor of OCD is that the sufferer is aware that what he or she is doing to combat the overwhelming anxiety is excessive and unreasonable. Sufferers do not enjoy ritualizing any more than they enjoy the terrible anxiety they are trying so hard to fight. People with OCD are not experiencing a disconnect with rationality, they are pained by the cognitive dissonance, i.e., “I know this is ridiculous, but it just feels so real and I feel I have to engage” is not an uncommon description of the inner turmoil.
There is much logic within the OCD as well. For instance, if someone is very concerned with environmental issues and values not being a litterer, they may be very meticulous to throw out their own garbage. If this person had OCD and was bothered by the garbage that is left on the street by others, the OCD may engage in an argument that they are hypocritical by not picking up other people’s trash. In fact, by ignoring it, they may be just as in the wrong as if they left it there themselves. OCD sufferers are very intellectually honest and this thought would be very intriguing and bothersome because they are willing to look into the thought and ask themselves, “is this true?!” They may engage in the following thought process: “I should pick up the garbage that I see as I walk down the street. But I can’t because that would take up so much time. But what if it’s up to me to set an example for others to follow suit? But I can’t be responsible for everybody’s actions; I can only do my part. But doesn’t that mean I don’t really care as much as I think I do about the issue? No, of course I care! But perhaps I’m not showing that I care by ignoring the garbage of others.” At this point, or further on in this internal argument, the person may feel compelled to pick up the garbage and that would be a ritual, and the additional difficulty is how far will it go?
Fortunately there is help. A combination of both medication and a specific facet of Cognitive Behavioral Therapy (CBT) called Exposure Response Prevention (ERP) is the recommended treatment. In general, one function of Cognitive Behavioral Therapy, is to help people examine their thought processes and identify possible cognitive distortions (erroneous notions and/or unhealthy and unexamined beliefs), and put them under the lens of logical scrutiny and analysis. The behavioral component then works in two ways: Firstly, changing behavior based on this cognitive process, so that by modifying the way we think we utilize our mind to help guide our emotions, make better decisions, and take more positive and healthy action. Secondly, taking steps to change behavior in the first place has a positive effect on mood, i.e., by changing our behavior; we can have a positive effect on the way we think and feel. We do not have to wait until there is inspiration and motivation to act, rather taking action can eventually stimulate inspiration, motivation and positive mood.
The cognitive element works a good bit differently with OCD. Since OCD’s underlying challenge is the intolerance of uncertainty and persistent doubting, analyzing cognitive distortions specifically about obsessions could actually be a form of ritualizing. For someone who struggles with social anxiety it may be remarkably helpful to review any unhealthy and unexamined beliefs they may have, and be able to see, through self-evaluation, where their thinking is flawed. If one holds a double standard for themselves regarding what is appropriate behavior at a party for instance, they may always live in great fear that everyone is judging them for the “fool they make of themselves.” In this case it would be helpful, and eventually very satisfying, for them to see where they are misjudging and holding themselves to a standard that they would not expect for anyone else. With OCD however, there always remains the window of doubt, the ever cycling, “but what if?!” The goal in ERP is not to show where the OCD sufferer’s reasoning does not add up, because with regard to their obsessions they are already painfully aware of the cognitive dissonance. Additionally, no matter how much it is proven that they have nothing to worry about there is always the “but what if?!” The goal of ERP than is to help gain an acceptance of uncertainty. This is an exceedingly challenging and difficult task, but it continues to be very effective. In Exposure-Response Prevention, OCD sufferers are exposed to the discomforting stimuli and encouraged to accept the uncertainty by not ritualizing and seeking reassurance. The acceptance is two fold. On the one hand accepting to live with uncertainty in general, just as it is accepted within things not pertaining to one’s obsessions. On the other hand accepting uncertainty within the specific obsessions. The acceptance is intellectual at first, the most difficult element is putting this acceptance into practice when the instinctual urges to ritualize are stimulated. This is not an overnight process by any means, and is something that requires much bravery and determination, as well as, personal understanding and love, in addition to the love and understanding of family members and close friends.