By Dr. Christian R. Komor
OCD Recovery Center
To truly understand what it means to have an Obsessive Compulsive Disorder (OCD) - in any of it's many manifestations, including Hypochondriasis, Body Dysmorphic Disorder, and Compulsive Hoarding - one must look beyond the obsessions, rituals and compulsions that attempt to seduce and imprison the sufferer. While obsessions and compulsions are the hallmark of OCD, "Special Characteristics" affecting self-image, relationships, career, life satisfaction, spirituality, emotional expression, parenting, use of leisure time and many other life areas are often present for the individual with OCD and need to be addressed as part of the recovery process. When one understands obsessive compulsive disorders as neurologically determined errors in the functioning of the basal ganglia region of the brain it is easy to see that having altered brain function can manifest in many ways other than obsessions and compulsions. The OCD Recovery Center have begun cataloging some of the more common thoughts, feelings, behaviors and physical problems that comprise these Special Characteristics of people with Obsessive Compulsive Disorder. While not everyone with OCD will experience all of these associated difficulties, knowing to look for them is the first step in understanding. Treating professionals who do not take the time to get to know these Special Characteristics are short-changing their patients.
The following outline is based on in-depth interviews with hundreds of people with OCD, reports from many treatment professionals across the U.S., controlled research studies, brain imaging and neuropsychological data. The Special Characteristics have been divided into three different categories: Lifestyle and Behavior (35 characteristics), Neuropsychological (25 characteristics), and Medical (8 characteristics). Due to space limitations only a few of the 69 Special Characteristics identified thus far will be discussed. Keep in mind this article is about developing awareness of these problems. There are solutions to these problems which this article is too brief to present fully. For each item discussed one self-help "Tip" will be presented.
It is unusual for a person with OCD to not have some amount of reassurance-seeking behavior. The tremendous levels of anxiety generated by OCD result in a desire to seek relief through the sharing of anxiety with others. People with OCD ask friends and loved ones to tell them they don't have to do a ritual, to help them perform a ritual, to give them information to resolve an obsessive question, or simply to accompany them ("If my friend can do this without washing their hands so can I"). Reassurance seeking is much like any compulsion in that it eventually needs to be reduced and the resulting anxiety faced step by step.
TIP: Either the client or their family can identify and then gradually (rather than rapidly) begin to reduce reassurance. Reducing reassurance gradually helps to minimize strain on relationships and allow time for replacement interpersonal skills to begin.
Anhedonia is a psychological term referring the absence of healthy hedonistic and spontaneous drives and impulses. As rituals and compulsions take over an individual's life it is easy to become a "human doing" rather than a human being. We forget how to just "be", how to allow life to just happen, how to exercise our free will. We control our environment, order, check and even obsess about our feelings - controlling them rather than experiencing them. ("Are these my real feelings or the result of an obsession?" "Should I be sad or angry now." "I need to have the same feeling all the time.") The result is depression and even depersonalization "Who am I? Do I even exist anymore or am I just a collection of obsessive thoughts and compulsive actions?"
TIP: People with OCD can practice spontaneity by asking themselves what they want to do or say - for example by starting at a physical location and then "wandering" where they feel like for 30 minutes.
When caught in the currents of compulsion it is difficult to see anything else. An unsuspecting person intruding on an OCD sufferer performing a ritual may be met with an attitude of "Let me alone. I need to finish this!" Interestingly, the same OCD sufferer later in the day may be found dwelling in the past or future - going over and over the compulsion in their mind to make sure they "got it right" or fearing the next time the agony of that compulsion will again be triggered.
TIP: Learning to "go with the flow" and deliberately focusing on the present moment is a skill that can be developed with practice.
Common obsessions are differentiated from Global obsessions which are broad encompassing concepts ("I may hurt people when driving my car.") and Intrusive obsessions which are fragments of awareness (such as a word, sound or smell). Common obsessions are normally directly connected to real life events and can occur frequently throughout any given day. Common obsessions can last several hours or even days, but tend to be self-limiting. They can be very bothersome such as an individual who is having lunch with their fianceacute; suddenly beginning to question if they are in love enough to marry, in spite of all evidence to the contrary, and then obsessing painfully about that for the rest of the day.
TIP: Learning to immediately detect situations and thoughts that are likely to be obsessive can lead to the ability to say "no" to the thought and step over it mentally before it becomes an obsession.
For people with OCD thoughts, concepts and awareness's can become "stuck" in the cortical-thalamic-striatal pathway of the brain. For the compulsive individual even eating, bathing, getting out of bed or making love can become a ritualized activity performed in a certain sequence to relieve the anxiety related to obsessions. Similarly, OCD sufferers frequently have difficulties with transitions such as shifting topics in a conversation or changing activities from reading to washing dishes. Often there is an uncomfortable feeling of not having done something right or complete enough - a sense of looking back and "holding on" to the last activity even if it distracts from the present. This may cause the OCD sufferer to appear inflexible when in fact they are simply focusing on an obsessional concern so intensely they become unable to transition forward to the next activity.
TIP: Practicing transitions in the sensory medium most problematic can be helpful. For example, an OCD sufferer with difficulties with auditory transitions can practice deliberately leaving a conversation or statement incomplete, moving on to another, and then leaving that conversation incomplete.
Another type of transition problem experienced by those with OCD appears to be similar to what is observed in Attention Deficit Disorder. It is not unusual for people with OCD to experience difficulties with relatively high levels of distractibility. It appears that this may be attributable to brain dysfunction associated with the OCD. In any event this distractibility can lead to impairment in learning, career and relationship.
TIP: Setting pre-defined breaks and reducing extraneous stimulation in the environment and increase concentration in the activity.
All living creatures must utilize adaptive energy to cope with negative and positive life change. Persons with severe anxiety disorders such as OCD tend to have less adaptive energy available and are rapidly stressed by change. This can include travel, moving residence, beginning and ending relationships, graduation from school, etc. Increased stress due to change can result in elevated anxiety and escalating levels of obsessions and compulsions.
TIP: Everything in moderation applies strongly in OCD. This includes change. Focusing on changes that are most essential or will bring the greatest reward and spacing out changes can be helpful.
Not only do people with OCD tend, as one might suspect, to obsess about choices, they also will often feel lost in "shoulds" and compulsions so that they lose awareness of their own spontaneous preferences and choices. This, in turn, may lead to questioning everything and a perplexing difficulty making choices.
TIP: Taking the first choice that comes into mind is often best. Later thoughts and choices will often be more influenced by obsessions.
Lining up media collections, methodically matching colors, touching objects in even numbers, keeping money in order by denomination - there are hundreds of obvious and subtle ways that folks with OCD practice symmetry. Often symmetry compulsions are less painful and anxiety provoking than other types of rituals, but are more difficult to divine and define.
TIP: Symmetry rituals can provide a good starting place for exposure-based therapy. As with much of OCD therapy simply doing the opposite of what the obsession is (e.g. messing up media that is lined up by release date) is what's called for.
While people with OCD tend to be very bright and creative, due to the interference from obsessions and compulsions they frequently are unable to learn and work at their potential. It is not unusual to find an OCD sufferer with a college degree working as a data entry clerk or even on disability.
TIP: Conduct career planning to provide gradual, moderate (versus severe or no) challenge to the individual's OCD. Focus on strengths and provide accommodations where necessary.
Doubt is an essential component of the OCD cycle. Almost all people with OCD when performing compulsive rituals doubt to one degree or another that they have performed the ritual satisfactorily or completely enough. This and other features of OCD lead to broader difficulties with trusting others and the world around them. These trust issues may emerge in very subtle yet very pervasive forms. For example, the individual with OCD may find themselves having difficulty trusting physical touch with others due to fears of contamination ("If I touch them I will become part of them.")
TIP: Trust issues tend to reduce as the individual works through their obsessions and compulsions in Exposure and Response Prevention behavioral therapy. Social Anxiety counseling may also be of assistance.
While looking back at recent compulsions that may not have been performed "correctly" and forward to compulsions that are dreaded in the future it is challenging for the OCD sufferer to stay in the present.
TIP: Setting a watch alarm to beep and remind one to come back to the present can be a helpful exercise.
Imagine growing up with obsessions and compulsions. While other children are enjoying relating and learning new skills on the playground you feel so much anxiety about being "contaminated" by playground equipment that you sit by yourself on the steps during each recess. Feeling defective and sure that something is wrong with you your self-esteem begins to slip away until you develop a deep social phobia and self-loathing. As an adult you are unable to follow your calling as a medical professional because your have a strong aversion to school and working with others situations.
TIP: Cognitive therapy is helpful in restructuring automatic negative thoughts and altering self-perception. Eye Movement Desensitization and other techniques can help to "remediate" development trauma.
Even without negative childhood experiences, such as in the example above, a significant percentage of people with OCD develop Social Anxiety. As with depression and attention problems there seems to be some cause to believe that changes in brain functioning are responsible. With the exception of Major Depression, Social Anxiety Disorder is the most frequently seen comorbid feature in OCD. Social anxiety can interact with some types of obsessions to increase their intensity and make them more difficult to recover from.
TIP: While Social Anxiety tends to be chronic in nature, identifying subtle and obvious avoidances of social situations and then gradually reintroducing those situations provides progressive relief for most individuals.
Obsessive Compulsive Disorders can be understood, in part, as disorders of control in response to heightened anxiety. This control can extend into the individual's emotions as well resulting in obsessions and mental compulsions about emotional expression with a corresponding depression of mood.
TIP: First listening to and then releasing inner feelings can provide a first step. Next, naming those feelings and sorting out which feelings are authentic and which are secondary to an obsessional thought.
People with OCD naturally become wary of and avoid when possible situations they have learned will trigger their obsessions and compulsions. This is especially true of children with OCD. In addition, OCD folks often report that their fears of not performing a compulsion and then being "punished" later by anxiety OCD ("Oh no, now I've done it.") are even more intense than the initial anxiety from refusing the ritual.
TIP: Learning that future anxiety is really just a part of the exposure and response prevention therapy process can be eye opening.
"What if I no longer have to worry about this obsession?" "What if I get to work early if I don't have to check for people I might have hit with my car on the way?" "Is it normal to wash my hands only once before eating?" Human beings are naturally drawn toward homeostasis, doing things a certain way over and over. The freedom of choice left in the wake of receding rituals can be uncomfortable and people with OCD may not know what is normal in situations where their compulsions have been in control for many years.
TIP: Actively learning what is normal and, or how to make good free-will choices is something that can be practiced in counseling or support groups.
Folks with OC disorders tend to show up with some predictable differences from "normal" when given psychological tests of brain performance and ability.
The most common neuropsychological deficit seen in people with OCD are difficulties with integrating sensory input through the five sense from the body and the outside world. The field of Sensory Integration therapy is traditionally practiced by Occupational Therapists. There are dozens of different techniques and several different approaches available.
TIP: Sometimes a repetitive activity such as kneading clay in the hand, chewing gum, tapping, rocking or humming can help the brain to better integrate input from the senses.
Memory, including non-verbal memory, visual-spatial memory, procedural memory, temporal ordering, incidental memory, memory for linguistic gist and dissociation between temporal memories and recognition all can affect people with OCD. Also, it is typical for people with OCD, especially those with compulsive checking behaviors, to have obsessive doubts relating to past actions - that is to doubt their own memory even when it is not faulty. (Researchers believe that this may be due to a deficit in non-intentional encoding of information and or visual recall.) These memory problems can be very perplexing and hamper behavior therapy.
TIP: There are a variety of techniques that can improve memory performance. A guide to some of the more common techniques can be found on the OCD Recovery Center web site. (http://www.ocdrecoverycenters.com)
The third common neuropsychological deficit is visual-spatial performance and visual attention. Person's with OCD will report increased levels of anxiety when in environments where there are a large number of visual "targets" such as malls, crowded restaurants and sporting events.
TIP: Often avoidance of over stimulation environments is called for. When this is not possible, using sensory integration practices such as those mentioned above my help.
Again, owing to the relative brevity of this article we will not focus in depth on the medical issues listed below. Further information is available through medical practitioners familiar with Obsessive Compulsive Disorder or the OCD Recovery Center.
Examining the many different ways that OCD can affect an individual's life can seem a little overwhelming, but is essential to the process of healing. Often these problems can lead to significant life impairment that must be addressed in order for optimal healing to take place. Identifying the Special Characteristics that an individual has is the first and most important step. Sometimes by just developing awareness of the problems and realizing they are part of the OCD profile strategies for healing will present themselves.