Should I Get Help for My Intrusive Thoughts?

We all experience intrusive thoughts like ‘Did I turn off the stove?’ or `What if I get sick with a serious illness?’ or ‘Would I ever jump off this cliff?’ Sometimes we take action to manage the anxiety that accompanies these thoughts such as double checking that the stove is turned off, seeing a doctor for new symptoms, and stepping back from the edge of a cliff. Consider consulting a specialist, however, when the intrusive thoughts cause you distress or inordinately consume your time. You may have a condition we call Obsessive Compulsive Disorder (OCD).

OCD Facts

OCD is a psychological condition characterized by obsessions, which are repeated unwanted thoughts, images, or impulses that elicit anxiety and compulsions, which manifest as overt or covert rituals aimed at reducing the anxiety associated with obsessions.

OCD affects 1.5 to 3% of the world’s population.

OCD is the fourth most common psychological disorder after depression, substance-use disorders, and anxiety disorders.

OCD symptoms range from mild to severe. About 9% of the population endorses subclinical symptoms.

OCD includes five symptom domains. Individuals can have any combination of the following obsessions and compulsions:

• • Contamination | Cleaning
  • Unacceptable thoughts | Neutralizing
  • Responsibility for harm | Checking
  • Symmetry | Ordering
  • Hoarding

OCD Treatment by Exposure and Response Prevention

The first-line treatment for OCD consists of a specific type of Cognitive Behavioral Therapy called Exposure and Response Prevention (ERP) and may or may not include pharmacotherapy depending on symptom severity. ERP is an evidence-based therapy with decades of randomized clinical trials supporting its effectiveness in treating OCD.

What is ERP?

Exposure refers to exposing yourself to the thoughts, images, objects, urges, and situations that make you anxious. Response Prevention means withholding the behaviors or mental acts that make you feel better.

ERP is a behavioral treatment meaning that clients get better by doing. ERP focuses on the here-and-now. In ERP, clients do what makes them anxious and practice not doing those compulsive behaviors that make them feel better. Why? Because anxiety is temporary. Empowerment that stems from changing an unhelpful behavior pattern is long-lasting.

What is not ERP?

ERP is not talk therapy that aims to reduce symptoms by providing insight.

ERP is not focused on the past.

ERP is not based on any spiritual or religious belief system.

Why does OCD not get better by itself?

Anxiety produces discomfort, so we want to avoid it to the extent possible. When anxiety peaks and becomes intolerable, the person escapes from the situation by avoiding it or performing a compulsion. This provides short-term anxiety relief that feels rewarding and reinforces the beliefs that (1) the feared outcome did not occur because the ritual was completed, and (2) escape is the only way to overcome anxiety. In the words of Dr. Paul Salkovskis, the solution becomes the problem. 

How does ERP work?

Nature designed our bodies to return to a state of equilibrium after a period of high anxiety. We call this habituation. In other words, if you stay long enough in an anxiety-producing situation doing nothing but being there willing to feel your anxiety, it will eventually subside. This gives you an opportunity to test out your fears.

You may think “I’ve tried to resist my compulsions before and the anxiety has not decreased!” In ERP, we conduct exposures in a very structured and systematic way. We define the feared outcome, what would constitute success for that specific exposure, and the behaviors to be done and not done during the exposure. Then we complete the exposure, wait however long it takes for habituation to occur, and observe the results.

We can test a few of the feared outcomes immediately (e.g., “I will not be able to tolerate the anxiety and will do a compulsion”) whereas others may require some time (e.g., “I will get sick from touching the toilet and eating a cookie without washing my hands.”) Yet others may involve unknowable outcomes in the future (e.g., “Something terrible will happen to my family”), in which case we develop an imaginary scenario to confront the situation in a hypothetical way. In each case, clients increase their tolerance for uncertainty as well as their ability to sit with their anxiety.

After the first few exposures, clients usually feel accomplished and hopeful for having confronted an anxiety trigger and having withheld compulsions. This builds momentum and motivation to keep going up the list.

Exposure examples

The therapist individualizes each treatment plan depending on the person’s core fear. Once we identify the core fear, the therapist and client collaborate on a list of anxiety-provoking situations ordered from the least to the most anxiety-producing. Then we move up that list. Examples of exposures used for contamination fear include

• • taking out the kitchen garbage with no hand washing afterwards,
  • touching the toilet bowl with no hand washing afterwards,
  • eating off the floor.

You may have a fear of contamination but not have these exposures on your list, since each person’s fear hierarchy builds upon one’s own core fears, symptom triggers, and avoidance behaviors.

How long does ERP therapy take?

ERP takes about 16 to 20 sessions, depending on the person’s specific circumstances and whether the person practices actively in their own recovery by completing between-session assignments.

What defines success in ERP?

We know that ERP worked when distress and impairment subside for clients, and they can perform the activities they previously avoided. At the end of successful treatment, clients feel that their quality of life improved. In addition, we measure progress with evidence-based assessments of OCD severity, which have standardized guidelines for defining treatment response.

Is ERP right for me?

ERP is right for you if:

• • Your OCD symptoms cause you distress or interfere with your ability to navigate through everyday activities or relationships
  • You have no comorbid conditions that need clinical attention first (e.g., severe depression) or you are managing comorbidities effectively
  • You prefer an evidence-based, data-driven approach
  • You can think outside the box
  • You are willing to practice exposures between sessions
  • You can openly discuss treatment barriers and resolve them collaboratively with your therapist

Recommended Resources:

• International OCD Foundation: https://iocdf.org/
• OCD UK: https://www.ocduk.org/

Photo by Vadim Sherbakov on Unsplash