Help For Primarily "pure" Obsessional Ocd

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        Obsessive Compulsive (OC) Spectrum Disorders are, for the most part, genetically determined neurological disabilities.  Due to their chronic nature they can be compared accurately to disabling diseases such as Diabetes, Epilepsy, Parkinson’s Disease or Alzheimer’s Disease.  OC disorders differ in that the symptoms and signs of the disorders are primarily internal and difficult to observe from the outside so that the sufferer often feels isolated and misunderstood.  

       Approximately one quarter of OCD sufferers have what is considered Primarily Obsessional” OCD of O-OCD (e.g. obsessions are predominant with few or even no compulsive or ritual behaviors that attend them.)  Like other forms of OCD, O-OCD is driven by abnormally high anxiety levels.  Perpetual doubt further increases anxiety with corresponding increases in obsessions and so on.  The situation is not helped by the fact that most obsessions have in them at least a potential kernel of reality.  The individual who obsesses that they might kill their child knows that some people have in fact committed this atrocious crime.  An individual obsessing about their hearing being damaged by a loud noise can read articles about rock stars and factory workers who have lost part of their hearing for just this reason.  It is often helpful to draw a “reality pie” for the individual illustrating how much reality there is to their obsession and how much of the pie (usually close to 99%) is obsession.

       At the OCD Recovery Center we have learned that the more “overvalued” the ideation is the more the OC sufferer is likely to believe that the thought has real substance and value.  Some O-OC sufferers have more insight into the unreality of their obsession than others, but all have some degree of awareness that the obsessive ideation is not “normal”.  Many hide the belief because of an awareness that others will not agree or will make fun of the belief if it were exposed.

        O-OCDS obsessions come in three general levels or types: Common, Global and Intrusive.  CommonObsessions are those that tend to pop up as part of daily living (“Did I just glass in my eye from that jar that my spouse dropped in the other room when I was not even around?”) Similar to Type II Diabetes, Common Obsessions cause discomfort, but usually not disability and are usually manageable through obsession inoculation techniques.    

         Global Obsessions are those pervasive, consuming, life-infringing obsessions that are usually highly disturbing to the individual and make it difficult to function in work, relationships and self-care.  Global Obsessions are often frightening and disturbing and many times center around such issues as religion, harming others, sexuality, bodily injury, or timeline distortions.

         Unfortunately, many individuals with Global Obsessions have no compulsion or ritual with which to undo or control the unwanted thoughts.  This is true helplessness as the thoughts just come unbidden throughout the day and the individual feels powerless to control them.  Often such individuals get into various forms of feedback loops as they try to resist or say “No” to the obsessions only to have them increase in response.

         People with Global Obsessions are actually less likely than the average person to act on the obsessive thoughts they have.  Indeed, most find the thoughts to be particularly tormenting as they run counter to the individual’s morals and ethics. Obsessions seem to have, if anything, an inverse correlation character and morals of the person or what is really happening or about to happen in a persons life. 

         Intrusive Obsessions are less common and often very difficult to remove.  Examples of Intrusive Obsessions include songs, noises, images, or phrases that replay over and over in the sufferer’s mind and seem impossible to shut off.  It is as if the individual’s mind becomes caught in an endless feedback loop.

         At the OCD Recovery Center we conceptualize obsessive thoughts in general like quicksand.  Analyzing the obsession simply makes it worse – just like struggling in quicksand.  More of the same leads to more of the same.  The more the individual focuses on the obsessions and attempts to figure them out, or struggles against them, the worse they become. 

         Obsessive tendencies tend to be cyclical based on life-phase, environmental stressors, and even season of the year.  Most people with obsessive tendencies do not totally eliminate that part of their personality, but it is possible to reduce the obsessions in strength and frequency so that they are not bothersome.  Performing compulsions to attempt to remove and take away the obsessive thoughts only tend to make them stronger. 

        Our first main task in dealing with obsessions is to separate ourselves mentally from them – to begin to see that we have obsessive thoughts, but we are not our thoughts.  A good way to start this process is by writing down the individual’s obsessions in list form, rating their intensity, listing what comes before the obsession (“trigger”.) and what comes after the obsession (“neutralizing strategy”.)  Becoming aware of obsessions, when we have them, what triggers them, what course they take and how they lead us to behave is the initial step.

        Our second main task is to habituate to the obsession.  This is different form desensitization where the individual is learning to accept a feared or anxiety provoking person, place of thing.  Habituation can be likened to the process we have all gone through when jumping into a cold lake or pool of water.  If we survive the initial shock and persevere by staying in contact with the water we will eventually become “used to it”.  As this occurs we stop noticing the water and our experience of it blends with our self-awareness so that the water temperature fades in importance until we forget about it altogether.  This is what happens in exposure-based behavioral therapy for primarily obsessional OCD.

Here are a few options for working with Primarily Obsessional OCD

  1. Encouraging the Obsession.  Make the obsession bigger than it presents itself as. (Instead of “I might stab my spouse with this knife.” “I am going to slash and gore my spouse with this knife and watch the blood splatter all over the floor.”  Other methods of encouraging the obsession include:  Writing out or saying the feared thoughts, acts, statements or sentences.  Reading books watching a video or making a scrapbook about the obsession; Deliberately going places where one will encounter the obsession; Taking part in feared activities; Resisting doing things the obsession says one must do; Making a card, t-shirt or other expression of the obsession.  Remember that this must be done primarily in the original medium of the obsession.  If the obsession is a thought – thinking and even worse thought will be more effective than looking at an image of an even worse thought.
  2. Discontinue as much as possible reassurance seeking.  This is crucial and some OC sufferers have reported significant reductions in obsessions simply by discontinuing reassurance seeking behavior.  The counselor or loved ones should give one reassurance statement (“No, I don’t think the individual’s eyes were damaged when one looked at the sun for that instant.”) and then offer no more – no matter how often, hard or pleadingly the individual asks.  Instead, as response such as “One have OCD and one are seeking reassurance again.” Can serve as a non-committal reminder to the individual that reassurance seeking is destructive to the treatment process.  Note that reassurance seeking and neutralizing behaviors can be very subtle.  For example, a OC sufferer suffering with obsessions of harming her children walks into the kitchen and sees a knife.  Simply leaning back away form the knife can, for some, be reinforcing to the OCD. 
  3. Break the rules.  The individual may find creative ways to challenge the obsessive thought.  For example, they may change the obsessive thought by adding an element in the middle or they may cut the thought off half-way.  Other options include delaying the obsessive thought or acting it out in pantomime very, very slowly.  The important feature here is to break out of the groove that the obsession has established for itself.
  4. Include the family.  Having a loved one participate in the treatment process (without providing unhealthy reassurance or enmeshing with the individual) increases the chances of treatment success significantly.
  5. Attention Training (ATT).  Attention Training is the primary tool used at the OCD Recovery Center for assisting OC sufferers in detaching from obsessive thoughts and reducing overvalued ideation.  ATT was developed by British researcher Adrian Wells and involves placing repetitive sound sources (television tuned to static, radio, fan motor) at similar sound levels in all four corners of a room.  The individual focuses their vision on a spot in front of them and shifts their hearing only from one sound to another in a randomized fashion gradually increasing the speed of the shifts from one sound to the next.  This technique, very similar to meditation, not only strengthens the individual’s ability to selectively focus attention, but also seems to “cool down” the obsessional part of the brain by “heating up” competing areas.  Like Massed Exposure, ATT must be practiced daily in order for it to achieve an effect.
  6. Meditation is an alternative for those who do not benefit from, or dislike Attention Training.  Meditation in its many forms provides a time-tested vehicle for strengthening the mind.  The stronger and more trained an individual’s mind becomes, the better they are able to dismiss and separate their awareness and self-identity from obsessive thoughts.  Meditation helps the individual to see that obsessive thoughts are unimportant and instead, visualize the obsession like a small cloud – notice it and then let it drift away.  Realizing that obsessions are of no real consequence helps to see them are “just brain noise” – the result of disordered impulses coming form the brain.
  7. Maintaining a healthy stress/relaxation balance is critical in recovery from O-OCD.  OC sufferers continually report that increased levels of stress cause increases in obsessions.  Likewise, having nothing to do also seems to stimulate obsessions for many people.  Balance seems to be the key.
  8. Yoga Breathing.  Researchers at UCLA developed and test a yoga breathing technique which reportedly reduced some forms of OCD by 70% or more.  The technique involves closing off the right nostril and breathing through the left (both inhalation and exhalation) for approximately 30 minutes per day.  The positive effects were seen over six to twelve months of daily practice.  Unlike ATT and ME this technique can be done while doing other activities such as watching television or riding in the car.
  9. Centering.  The primary skill needed to transcend obsessions is to shift the individual’s focus inward (through centering, physical techniques, etc.) and then actively relax.  “Centering” is an excellent mind-body tool for keeping the focus on ourselves and not projecting.  Centering involves focusing attention on the geographic center of the physical  body – known as the “hara” in Japan. 
  10. View anxiety as the fuel that causes obsessions to appear.  Developing active methods for    anxiety reduction tends to reduce obsession.  The OCD Recovery Center offers several handouts on this subject.

  11. It is essential for the individual to simply feel the anxiety that comes up when one are confronting an obsession.  This is very important.  If one does not give in to an obsessive thought the anxiety connected to that thought is almost certain to rise.  This is normal.  The simple but extremely difficult task is to watch the anxiety and allow it to be there.  It will gradually drop time (How much time varies widely from minutes to months!) and this is how real positive brain change happens.  Remember, those with OCD are confronted with two choices:  Feel the anxiety and refuse to ritualize and perform compulsions or feel the anxiety and give in to what the OCD is asking one to do.  Either way there is anxiety.  In the former there is anxiety that leads to eventual recovery.  In the latter there is anxiety, relieved by compulsion – leading to further enslavement by the OCD.  OCD can be thought of as a blackmailer that is never satisfied.

  12. Attempting to suppress thoughts almost always has the opposite of the intended effect – making them stronger still.  Thought stopping in all it’s various forms (e.g. rubber band snap on the wrist), while helpful for other situations is likely to make obsessions worse for this reason.
  13. Likewise, for another person to try to point out the unrealistic nature of an OC sufferer’s obsessions is at the least unhelpful and at worst will strengthen the obsession.  Obsessions by their very nature do not make sense in the same way that an epileptic seizure does not make sense.  It is simply a brain dysfunction – a random spike of energy or “short circuit”.

  14. Learning to tolerate the unwanted thoughts and not avoid or escape them – however that is accomplished in a particular situation or setting – is the antidote to O-OCD.

  15. For Intrusive Obsessions creating brief exposures (e.g. turning off and on the part of a song that gets stuck in the individual’s mind) may be helpful.

  16. Neurofeedback is another emerging tool for confronting obsessions.  Neurofeedback is done with a highly trained psychologist who first makes a “brain map” of the individual using computerized electroencephalograph equipment.  The individual is then given a video game to play using their mind.  In order to make the game operate the individual must achieve the desired brain state (e.g. non-obsessional, low-anxiety, etc.).
  17. The One-Second Rule.  If the individual is tempted to obsess about a body sensation, thought, or other item they can be instructed to allow themselves only one second to think about it.  Then they redirect attention to something closely related (e.g. another body sensation).  Finally, they redirect attention to something else they would like to do or think about.  (This is sometimes called “selective attention”.)
  18. Obsessions are “projections” of our self into the past, the future, other people, etc.  Focusing on the present and what the individual is doing right this moment diminishes the hold obsessions have.

  19. Humor.  Is very important in obsession recovery.  OCD wants the sufferer to take it seriously.  Finding ways to make fun of the obsession (“And now Dr. Evil is going to kill
  20. Focusing the mind on positive circumstances or behaviors rather than the obsessions or what might be “wrong” tends to decrease some obsessions.  A good way of doing this is by making a “gratitude list” at the end of each day – listing what one is grateful for in their life.

  21. Encourage a “Just be and don’t think” attitude on a continual basis. Obsessions live in the mind. Redirecting the attention always back on experience versus thoughts helps calm down obsessions.

  22. Shadowing.  Following someone the individual trusts through a behavior that has been difficult due to obsessing can help to break the obsessive routine or rut. 
  23. Obsession Box.  Place a copy of the Serenity Prayer on a box or bag.  The individual can then write down an obsession, place it in the box, then let it go mentally.  If they begin to worry about it again they can remind themselves to “put it away”.
  24. Thought Backtracking.  Instruct the individual to notice when an obsessive train of thought begins – then think of the thought like a train and reverse the direction.  What was the thought they had before the current one?  What was the one before that?  What was the initial thought (“engine”) that started off the thought train?  When the sufferer arrives back to the original thought – almost always something involving the material world, five senses and real, present-time experience, instruct them to stop and focus on enjoying that.  Note that Thought Backtracking is different than what is known as Thought Stopping – which does not generally work for OCD.
  25. Catharsis can be illusion.  One of the difficulties for individuals with obsessional thinking is that it is difficult to trust one’s own ideas and feelings.  Many times it becomes important to set limits on “self-exploration” (e.g. delving into childhood trauma) because the obsessive ideation is distorting the situation out of proportion.  Usually it is best to stay in the here and now and deal with the obsessions.  At least by doing this first one can say, “If I get past these obsessions and I still have issues about the past or certain people then I can focus on that line of inquiry.  If the obsessions are being powered by blocked emotions – especially from traumatic life experiences the individual can find a safe way to feel and express feelings (tears, anger, fear, grief, etc.).  A technique called Eye Movement Desensitization and Reprocessing (EMDR) works well for this purpose (although people with OCD often respond differently to EMDR than other subjects).  For people with OCD feelings can be more of an illusion than an answer. 
  26. Slow Motion Focus.  If the individual tends to become stuck in a particular behavior it may be helpful to try going very, very slowly through the behavior.  For example:  Put in the key…wait…turn the key…wait…pull the key out…wait…turn the knob slowly…wait…open the door slowly.
  27. If the individual is having trouble getting free of an obsession, try having them try changing the setting.  Suggest a day off to go to the beach, grandparents, visiting  friends, hiking, etc.  They can take note of positive changes experienced and take these experiential learning’s back to the regular routine.

  28. To combat obsessions it is helpful to take some time each day to practice “Non-doing”. This means just sitting without any purpose or activity and working to just be aware  of sitting and experiencing the environment with the individuals five senses. 

  29. Saying “No” to shoulds tends to lead away from obsessions.  Giving ourselves freedom of choice and the ability to listen to our own desires is the opposite of obsessing.  Encourage this in the individual’s daily routine.
  30. Sometimes obsessions can be the result of difficulties with memory (e.g. obsessing about what signs say, or if the stove is turned off).  Explore if this might be the case for the individual.  If so, develop memory tools to assist the individual.

  31. Ritual Delay.  This involves delaying acting out a compulsion, which will reduce the individuals anxiety about an obsession.  For example, waiting 60 minutes and then asking the individual if they need to do the neutralizing ritual or if the obsession is “just brain noise” to be ignored.
  32. Have the individual keep in mind the idea of an “Obsession Pie”.  Visualize a pie with a very small slice darkened in.  This slice represents the reality of the individuals worries – most worries have at least some basis in reality. The rest of the pie represents obsession.  Our job is to reduce the obsession part of the pie.

  33. Ah… Every word the human race has created for God has the sound “ah” in it.  Making this sound creates a pleasant and anxiety reducing vibration in the body.  The next time the individual finds themselves obsessing have them try making the sound “ah…” for five or ten minutes and see if it doesn’t shift their focus to more pleasant and rewarding experiences.
  34. Compulsion Substitution.  In an emergency, instead of the individuals usual obsession try substituting tapping gently three times on the head.  Let this satisfy the OCD for the time being until other tools for recovery can be developed.  Keep in mind that compulsion substitution will probably encourage the obsessions when used.
  35. Help the individual to find their “want to”.  Free will and choice are the enemies of compulsion and obsession.  Try asking the individual here and now in this moment what they want to do or say.  This may be very scary since they are used to doing what the OCD tells them they “should” do.  When the individual gets the hang of it, though, it can be very freeing!
  36. Encourage a sympathetic self-view.  Having an obsessive-compulsive disorder is difficult, stressful and time consuming.  Remind the individual not to expect themselves to be able to accomplish what they could if they did not have a disability.  Encourage them to be understanding and to take it easy on themselves. 
  37. The Head Shake Technique.  If the individual finds themselves obsessing suggest they simply shake their head as if shaking the thought right out of their head. 
  38. Rubber Band Technique.  Place a rubber band on the individual’s wrist and have them snap it when the individual notices them self-obsessing.
  39. Encourage the individual to keep in mind some helpful slogans and reminders such as:  “Relax.”  “De-escalate.”  “Disinhibit.”  “Be spontaneous.”  “Detach.”  “Let go.”  “Accept.”  “It’s ok to have things be imperfect.”  “Lighten up!”  “Say “So what!”.  “Live in the now.”

  40. The oriental practice of Qigong is very helpful in reducing the anxiety and providing a healthy activity to do while experiencing the anxiety related to ERP work.  The OCD Recovery Center can provide training in basic Qigong, or direction to a practitioner or video training series.

  41. Finally, be aware of the possibility of “neutralization obsessions” which involve the replaying in the individual’s mind of an anxiety producing event.  Although this may look like obsessing is can actually be a form of self-stimulation in which the individual replays an event or circumstance, perhaps to “get it right”.  Instead of confronting anxiety this leads to a perpetuation of the anxiety.  Instead of traditional ERP neutralization obsessions call for a “letting go” approach in which the they are encouraged to simply let the thoughts flow through them without hindrance.

CENTERING: A NOVEL ANTI-OBSESSIONAL AGENT

            OCD, Hypochondriasis, Body Dysmorphic Disorder and the other OCD-Spectrum disorders are driven by anxiety.  As anxiety reaches a certain level within the individual it triggers what appears to be an “obsession circuit” in the orbital frontal cortex of the brain.  These cognitive obsessions then generate behavioral compulsions designed to reduce the anxiety the individual is experiencing.   This compulsive behavior, unfortunately, has the opposite effect of further increasing anxiety and doubt.

     While many individuals with OC-Spectrum disorders are able to target compulsive behaviors, which they can address in exposure and response prevention (ERP) behavior therapy, others must cope primarily with obsessions.  Know as “Pure-O” in the literature, it is generally agreed that obsessions without clear externally observable behavioral elements are far more difficult for the individual to surmount.  The notoriously difficult to treat Body Dysmorphic Disorder is one example of such a highly obsession-dominated condition. Often OC sufferers with BDD and similar highly obsessional conditions must rely solely on pharmacological solutions.

       The primary dynamic, which occurs during an obsessional episode, is a focus of attention outside of one’s own body or personal field of awareness.  When we obsess our attention goes outward from our consciousness into another time (future or past), another person, or a imagined reality (distortion or exaggeration of a body defect or deformity) or situation (the bump in the pavement that may have been a body being run over.)  To break the obsessional cycle it is thus necessary to shift focus back inward.  The popular Alanon saying of “Keep the focus on self” can summarize this act of refocusing attention inward.  Two of the most effective tools for accomplishing this are: (1) Deliberate relaxation, and (2) Centering.  For the purposes of this article our focus will be on the latter.

        It is important to remember that it is anxiety that is at the root of obsessive-compulsive behavior.  Anxiety, of course, is a seemingly primal response which humans have in situations of tension or danger – what has come to be known as the “fight/flight” reaction.  When we are frightened or under stress we seek to either attack the source of our stress or run away from it as fast as possible.  When one has an anxiety disorder the fight/flight alarm system is being triggered frequently without due cause.  The act of centering takes the individual out of the fight/flight modality and returns the concentration to a more adaptive orientation of self-ownership, relaxed preparedness and self-possession.

         Centering is a true mind/body technique developed initially for use in martial arts settings, especially in the arts of Aikido and Judo.  Martial artists, ballet dancers and other athletes learn to maintain a proactive  focus on the geographic center of their physical body – known in Japan as the “hara”.  In the case of the martial artist, centering facilitates a maintenance of concentration on one’s own movements rather than being distracted or drawn off into reacting to an opponent’s behavior. 

         In daily life centering is often used in communications-skills training where people have become uncentered and are acting in an overly aggressive/forceful fashion or, (conversely) in an overly passive/submissive manner.  Both imbalances tend to create interpersonal anxiety.  A more “centered” response is to look inside and then make an “I statement” concerning ones thoughts or feelings.  For example, “When one step on my foot I feel uncomfortable and I would like one to get off my foot” versus “One are a clumsy fool”.

        In OC-Spectrum obsessional disorders the mind/body act of centering can quickly shift the focus off of the obsessional person, object, or situation and back onto the reality of ones moment-by-moment experience.  When we teach our obsessional OC sufferers to  “center” we begin by asking them to focus their attention on the exact geographic middle of the physical body.  That is a point an inch or two below the naval and in the center of the abdomen.  Just as one can hold out the individual’s hand in front of one and feel the sensation of opening and closing the individual’s fingers, one can develop a “feel” for this center point in the individual’s body.

            Once a sense of this center point of physical anatomy is developed, it can be used as an intervention in times of high anxiety when obsessional cognitions have begun to take over.  By focusing on this center point, attention shifts inward and internal balance becomes re-established.

            In order to “test” one’s centered state, simply ask someone to give one a gentle push on the front of the individual’s shoulder while standing side by side with one.  The individual’s immediate tendency will be to become aware of the touch on the individual’s shoulder.  This is a metaphor for the way in which obsessions distract us from our center.  When this occurs do not resist the touch on the individual’s shoulder (obsession) – this will only get one more caught up in it.  Instead, just refocus the individual’s attention on the individual’s center point – regarding the shoulder touch (obsession) as irrelevant to the individual’s true needs, purpose and goals.  (Note:  In the test situation, if one find the individual’s body wobbling when one are touched it is likely that one are not centered.  If one feel a sense of solidness and stability one have mastered the centered state.) 

The author, Christian R. Komor, Psy.D. is a clinical psychologist who combines 12 years of clinical experience treating OCD-Spectrum disorders with discoveries from his personal recovery from OCD.  Dr. Komor is the author of The Obsessive Compulsive’s Meditation Book (2000), OCD and Other Gods (2000), and The Power of being (1992).  Dr. Komor (dr.komor@gamil.com) is the founder of the OCD Recovery Centers of America based in Grand Rapids, Michigan.  The Center offers Intensive Outpatient and Housecall programs in additional to individual and family psychotherapy.  For more information visit the OCD-RCA web site at www.ocdrecoverycenter.com

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