Mental Rituals, OCD, and ERP

I’m excited to introduce ocdtalk’s first guest blogger! Seth J. Gillihan, PhD, is a licensed clinical psychologist with a practice in Haverford, Pennsylvania. He completed his doctoral training at the University of Pennsylvania and specializes in cognitive-behavioral treatments for anxiety and depression. Dr. Gillihan is also a visiting assistant professor of psychology at Haverford College and a Clinical Associate at the University of Pennsylvania, Department of Psychiatry.

Let’s give him a warm welcome (I can hear you all clapping)……….

Some of my colleagues and I recently wrote an article about common therapist mistakes in exposure and response prevention (ERP) therapy for OCD. I wanted to highlight one of the sections of that paper that may be helpful to individuals whose compulsions are primarily mental. Mental compulsions typically involve words, phrases, prayers, and so forth that the person says silently in order to prevent a feared outcome, or to reduce the anxiety that the obsession causes (see full article for a list of common mental compulsions). For example, a person might have religious obsessions and may fear that her children will become sick if she has blasphemous thoughts. In response to any blasphemous thoughts or images that come to mind she will repeat to herself a memorized prayer about the greatness of God with requests for protection for her children.

The first step in treating OCD that involves primarily mental rituals is to recognize the familiar cycle of obsessions and compulsions. Just like with observable rituals, mental rituals maintain OCD by providing temporary relief from the OCD-related distress. Some clinicians may fail to identify covert/mental rituals, and people with OCD similarly may have a hard time distinguishing between an obsession and a mental compulsion. When thoughts are coming quickly one after another, some causing distress and some intended to relieve that distress, it can feel like a jumbled mess and the compulsions can be hard to identify. For this reason OCD with mostly or only mental rituals is often mistakenly labeled “Pure Obsessional” (or “Pure-O”) OCD.

The way to tell a mental compulsion from an obsessive thought is to ask what the function of the mental act is: Obsessions increase anxiety whereas mental compulsions are intended to decrease anxiety.

Once a person knows what his or her mental rituals are, it is crucial that the person eliminate them in order to recover from OCD. During ERP the individual must avoid doing mental rituals during exposure—for example, saying ritualized mental prayers to neutralize the fear of harm that comes from doing the exposures.  These kinds of private rituals undermine the exposures and can prevent the person from getting better.

As discussed on an earlier post, ERP for mental rituals requires one to do the opposite of the rituals and allow oneself to have the distressing thoughts like “I’m a devil worshiper,” without any mental rituals to counteract these thoughts. Easier said than done! A lot of the difficulty, of course, comes from the almost automatic nature of the mental rituals; people with OCD often say they do a mental ritual even when they’re trying not to. For this reason the ERP therapist and person with OCD will need to work closely and creatively together to find ways to block the mental rituals.  One solution is for the person with OCD to read out loud material that provokes obsessions (either in vivo or imaginal exposure—see sections 3 and 6 of the article for descriptions of these two techniques) so that the mind is not free to perform mental compulsions. It can also be helpful to say exposure statements to prevent mental compulsions, such as saying “I’m friends with the devil” instead of engaging in a ritualized prayer. Exposure statements should also be used if the person realizes he or she performed a mental ritual—what is often called “spoiling” the ritual.

A final point that we highlight in the article is that it’s usually counterproductive to tell oneself “that’s just my OCD” and similar statements when experiencing an obsession. These kinds of statements play OCD’s game of looking for certainty and trying to find a short-term fix to make obsessions less upsetting. As such, these responses to obsessions often become a ritual, another way to neutralize the anxiety and uncertainty that the obsessions cause. A more effective long-term solution is to answer obsessions with exposure statements that recognize uncertainty: “Maybe I did sell my soul to the devil”; “God might punish me for having that thought.” While I’ve focused here on religious obsessions as an example, these principles apply to any obsessional content.

The bottom line of this discussion is that, contrary to what some people with OCD believe or have heard, ERP can successfully address mental rituals. Armed with knowledge about how to recognize mental compulsions, determination to conquer them, and often with the help of a skilled therapist, individuals with mental compulsions can live more enjoyable and fulfilling lives.

Questions or comments? Please post them here or contact me by email.

Thank you, Dr. Gillihan!

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125 Responses to Mental Rituals, OCD, and ERP

  1. Thank you for a very informative post. This was very helpful to me and gave me some good ideas because I have religious based mental obsessions at times and have struggled to deal with them.

    • Ceci Harlan says:

      I have a family member who tried ERP about ten years ago. The effect wore off within two years since she didn’t do any after care with a therapist. It does work, but the client has to stick with the program.

    • Ceci Harlan says:

      My family member participated in a three week intensive ERP program. The effects were great while they lasted. I suppose that it was just easier for my family member to go along with the rituals than to do the incredibly uncomfortable ERP. That was about ten years ago; since then the OCD progressed a little more day by day (some days were better than others) so that now it’s completely disabling. It’s a very sad situation.

      • Thanks for sharing, Ceci and I’m sure it is heartbreaking to see improvement followed by regression. A lot has been written about recovery avoidance that might be helpful to you in dealing with and understanding your family member’s situation. Of course, ultimately, the decision to work toward recovery can only truly be made by the person with OCD. I wish you and your loved one all the best.

      • sethgillihan says:

        Thank you for sharing your family’s story, Ceci. I agree with Janet that it’s heartbreaking to see, especially when the person has put in the hard work needed to improve, and has tasted what recovery can feel like. Sometimes I think of intensive ERP as being like molding clay–after treatment the shape might be right but it’s not “set” yet. It takes continuing practice to solidify the gains made. If lapses start to pile up and point toward a relapse, it’s probably time for at least a brief ERP “tune-up.” I hope things do turn around again.

  2. ocdtalk says:

    Glad you found it helpful, Tina. I thought it was an important post also.

  3. krystallynn says:

    Sometimes I will mentally go over a action or activity I performed previously in a compulsive manner. For example I have checking rituals and all of a sudden it will occur to me, hours later, that I did not check good enough that the bathroom door was closed or the shower curtain, something to that nature, and instead of going to physically check it again, I will try to picture it closed, over and over till I feel better. Quite exhausting, it is no wonder I get headaches. I suppose this qualifies as a mental compulsion ? though I think before reading this I was halfway convinced that because I did not actually go check, I was doing something positive. I say halfway, because obviously I was still distressed so I was not fooling myself.
    What I took from this, is that what that thought occurs, instead of trying to picture it, I need to think that it is indeed not closed and then sit the anxiety out. The really sad and crazy part is that deep down I know it doesn’t matter..half the world probably leaves their shower curtain open and why mine has to be closed and hanging in perfect, even folds is just stupid. Sorry to ramble on..bottom line, I did find this post helpful.

  4. ocdtalk says:

    Krystal Lynn, I think your comment is a great example of what Dr. Gillihan is talking about, and also illustrates how exhausting these mental compulsions can be. And yes, I believe “doing the opposite” would be imagining the shower curtain open, just as you say. Thanks for sharing….you really give those of us without OCD a taste of what it’s like.

  5. 71º & Sunny says:

    Really, really great post! Thank you Dr. Gillihan. I will gladly pass this very informative post on.

  6. ocdtalk says:

    I agree, Sunny. It is definitely worth passing on!

  7. Rae says:

    I am having trouble knowing if I’m having mental compulsions or obsessions. so I am not sure what I should be doing? Any help?!

    • ocdtalk says:

      As Dr. Gillihan says, “Obsessions increase anxiety whereas mental compulsions are intended to decrease anxiety.” Hopefully this will help you figure out which is which. I would strongly advise finding a therapist who specializes in treating OCD..as you know, it can be quite complicated! Good Luck!

    • It’s a great question, Rae, and I agree that it may be very helpful to be able to discuss the specifics with a therapist skilled in this area. Some writers have described obsessions and mental compulsions as being like “two voices,” one that raises anxiety and one that tries to lower it. For example, a person at work might imagine a fire from leaving the stove on at home (the obsessive thought), and then do “mental reviewing” to try to ensure that they turned it off, or to reassure themselves that they did in fact turn it off (the mental ritual). In ERP for OCD we would encourage a person to “turn up” the first voice–to expose themselves to the anxiety and uncertainty that the obsession raises–and to prevent themselves from engaging in the mental ritual. As the article mentions, it can be a challenge to block the mental ritual, and often takes creativity on the part of a therapist and the individual with OCD.

  8. Arka Bhattacharyya says:

    Very warm thanks..helpful post…When obsession comes in mind;it seems that there is brain lockout.Brain is not going in normal rythm.So I have to do some mental rituals to neutralize negative thought and get some relief.But all the effort goes in vain and ocd attack again and again….

  9. ocdtalk says:

    It sounds as if you are caught in the vicious cycle of OCD, Arka. I know it’s easier said than done, but it’s best not to engage in the mental rituals at all.

  10. Thank you for your comment, Arka. What you’re describing must be familiar to so many people with OCD–feeling compelled to do something to get a little relief in the short run, and in the long run feeling stuck in the cycle of obsessions and compulsions. I do hope you’re getting or are able to get some effective treatment. I wish you all the best.

  11. charles says:

    Hello

    First im an ex-ocd sufferer , so people out there don’t loose hope it can be treated! The reason im posting is i founded the article interesting in a way but has a HUGE mistake . It give the impression that ERP is THE sollution for mental ocd and if you dont perform ERP you probably won’t succeed in beating ocd . Don’t get me wrong ERP is a good way to treat ocd but i personaly, like thousand of people , used sometime totally different called Cognitive Therapy…I used a lot of the 4’s step method , wich focus on NOT trying to make the tought go away but rather telling yourself it is not bad or good , ITS just a ocd tought , no need to check its just ocd and refocus yourself on something usefull…At the end of the day laught at it its just ocd and never forgot it can be cure…Like i said don’t get me wrong ERP can work but what a lot of therapist don’t tell you is that a lot of people failed with ERP ( i did with a specialist on mental ocd ) , its depend on your personality and your belief on the method . My ocd was count and remember insignifiants things and if i was not mentally checking i was having A LOT of anxiety.

    Hole i helped some and sorry for my english ( im french )

    charles

    • ocdtalk says:

      Hi Charles, I appreciate your comment and am glad to hear you are doing so well. While ERP Therapy also does not focus on making thoughts go away, there do seem to be some differences in what you are describing and ERP Therapy. I will leave this for Dr. Gillihan to address, but I am happy you found therapy that worked for you.

  12. Debbie says:

    I deal with mental compulsions as to something i recently did EXAMPLE making my baby’s bottle did i put the correct amount of water and correct amount of formula? always in doubt it can be exhausting. I found this post quite helpful thank you Deb

  13. Yes, Charles, thank you for your comment, which I thought was very clear. You raised some interesting and important issues.

    I appreciated Janet’s clarification that ERP does not focus on making thoughts go away; as I wrote in the post above, ERP involves “allowing oneself to have the distressing thoughts.” The four-step program you described actually has very similar elements to those of ERP: Exposure to the obsessions and stopping the rituals are key aspects of both treatment approaches. In fact, the studies that Dr. Jeffrey Schwartz and colleagues did on OCD and the brain used ERP “facilitated by cognitive techniques” as the psychological treatment (see Baxter et al., 1992; Schwartz et al., 1996).

    ERP is described as the first-line psychological treatment in the American Psychiatric Association’s guidelines, published in 2007 and “reaffirmed” in 2012 (http://www.guidelines.gov/content.aspx?id=11078#Section420). They note that there is currently not sufficient evidence to conclude that cognitive techniques enhance the effectiveness of ERP.

    At the same time, just because the majority of people with OCD respond to ERP treatment doesn’t mean that everyone will! And so it’s good that you found something that worked for you. I would just reiterate that it seems that for many people with OCD, making *sure* that obsessive thoughts are “just my OCD” becomes a ritual, and so the individual and the therapist need to be careful if they decide to use that kind of relabeling. I’m speaking here from my clinical experience, not from studies that I’m aware of about this phenomenon.

    Thank you again for taking the time to share your thoughts and experiences.

    (For those who are interested, the four-step program developed by Dr. Jeffrey Schwartz and described in his book “Brain Lock” is summarized here: http://ocduk.org/four-steps.)

    • charles says:

      Thanks for the reply Dr.Gillian!

      Just one thing I may not have explain well. When I was telling my self ”its only OCD that try to make me check or its ocd i dont need to check” Im actually NOT trying to make the obsessions go away but to resist the compulsion . I accept the fact that I have these tought but I use strategy to resist the compulsion . I think its very important to explain the difference cause a lot of therapist who wrote on the subject emphase on ”expose” yourself to the problem but they rarely give tips to resist the compulsion and this is the key . Theres some , like who I was , who only have compulsion and no really obsession ( ocd counters , ocd trying remember specific details for no reason ect…) and strategy to resist mental checking is the key to end there nightmare!You cannot ask a Pure O to accept the fact that the ”may” harm someone and to just resist compulsion …especially mental compulsion..You need more and theres rarelly an article on strategy to resist mental compulsions .Like i said I found the article very interesting but I think it may be a good idea to talk more on how to resist mental checking and explain that telling yourself its just ocd is NOT resisting the obsessions!

      Thanks Dr!

      • Thank you for the follow-up thoughts, Charles. As you wrote, exposure alone is not enough–it’s crucial that people with OCD learn ways to resist completing compulsions. Things that help in that regard should be helpful in the treatment of OCD. I appreciate your comments!

  14. ocdtalk says:

    Thanks for the clarification, Dr. Gillihan. I know many people have found “Brain Lock” extremely helpful.

  15. mike says:

    Hello ( sorry for my english In from Qc Canada )

    I have a question regarding the Response prevention in ERP . If Example my ocd is around fearing being gay , i heard Therapist said during exposure to react by saying to yourself ” Im gay im gay!!” and others therapists by ”I MAY be gay” and others therapist said to react by ”accept the tought without giving any signifiance you PROBABLY not gay” . I really found this confusing , i mean if I fear being a killer , Do I tell myself ”Im a killer” or ”I MAY be a killer’ or ”Accept the tought mike eithout giving any signifiance”….My point here is Do i have to believe what im fearing 100% or believe the possibily i MIGHT . Because I heard different answer from the therapists !!

    Thanks for the help I really need it!

    • It’s a great question, Mike, and I’m glad you shared it. The problem that I’ve found with asking some people with OCD to tell themselves in ERP that “I’m gay” (or similar exposure statements) is that the person just doesn’t buy it. Then the person might start to worry that “I don’t believe it 100%” and then THAT can become a source of worry and distress.

      The point of the exposure statement is to increase the person’s anxiety in the short term by not fighting against what OCD is “threatening” the person with. I work on a case-by-case basis to find what kinds of statements are most effective for a person. If the statement is increasing exposure-related distress then one is probably on the right track. In general I’ve found that the “maybe” or “it’s possible” forms of statements most often are the best–OCD hates uncertainty–and again it can vary from individual to individual.

      All the best to you.

      • mike says:

        Thanks for the reply Dr!

        These are great advice ! One last thing I forgot I would like to have your opinion . Recently I’ve beeing doing great using a Technique some therapist and forum member use and what I think is ERP : every time I feel an obsession I accept it and instead of ignore it I just let the tought there without giving any signifiance..Im like ”Its a tought separe from Who I am , I dont need to check if I am or Maybe , I accept the tought but NOT the signifiance of the tought”…I do not use statement like ”Theres a possibility i might be crazy” ”Im friend with the devil” ”I may be gay maybe not”..I dont give any signifiance and it reeeeaaally work , I can easialy resist the compulsion .So my question is : I’m I doing ERP right now? Because each time I read about ERP the response prevention part look about the same ( tell yourself its a possibility your obssesion is true and with that you can resist the compulsion..) . It is okay to say that the goal of ERP is to accept the obsession and resist the compulsion , wheter it is with the old ERP style ( I friend with devil , i might be gay ectt) or by telling ”I accept the tought without giving any signifiance” or by any technique that work for you??

        Thanks for the help !! and like I said I’ve being doing better but reading about ERP brought me a LOT of confusion , I was on the right track but reading old erp technique made me doubt :/!

        Thans for the help DR!

      • Again, Mike, that’s a really great question. My guess is that some clinicians would say it’s part of ERP and others would label it a more “acceptance based approach.” Of course, there has to be some measure of acceptance even to engage in ERP (see an earlier post in this blog).

        In my view the goal of ERP is to get where you’re describing, where a person can still have obsessions from time to time without getting wrapped up in them or even needing to respond at all. My general pattern is to use the more “head on” responses during the acute treatment phase; once the OCD is more under control the person might shift to just letting the thoughts be there without believing that a direct response is necessary. Sometimes we’ll use the “noisy neighbor” metaphor in which the “neighbor” (OCD) can make noise and the person can continue to go about his or her business.

        The reason I don’t tend to use the more acceptance-based approach initially is that it can be easy for a person to fall into the trap of doing subtle mental rituals by saying things like “I accept the thought but not the significance of it,” with the intent to quickly reduce their anxiety. OCD can be sneaky and insidious and will find a way back in if it can.

        Finally, I think it’s important to point out that for some people with OCD the goal can become to “do the therapy perfectly,” which then becomes its own area of obsessions and potential compulsions. When that’s the case I usually encourage the person to do good ERP and not perfect ERP.

        I hope this helps!

  16. ocdtalk says:

    Hi Mike, thanks for commenting. I know ERP Therapy can be confusing. I’m not a therapist and therefore don’t feel comfortable advising you……Maybe Dr, Gillihan will comment on your questions.

  17. mike says:

    Thanks Again Dr!

    Im still very confuse , I just read Brain Lock and it says the exact opposite what you say about resist compulsion..I guess I will stick with your method even if brain lock seemed to work with me . Im probably gonna stop reading about ocd because I hear 1millions different way to do ERP ( ”Im gonna harm someone” ”I might harm someone” ”theres a possibility I harm someone but probably not” ) and theres The brain lock strategy who seems to have worked for thousand of people but whos techniques to resist checking is FAR different from ERP ( accept , relabel as not you but ocd and refocus on something helpful…instead of making you believe you might harm someone)

    In regards of all these methods , it is okay to say , any methods is good ( even brain lock ) as long as you resist compulsion ?

    Thanks Dr and like I said I will probably focuse on your methods..!

    • Hi, Mike. As Janet noted above, many people have found “Brain Lock” to be very helpful, and it’s hard to argue with success! It might be helpful to see comment #20 above where I address some of your questions.

      All the best!

  18. Laura Stivers says:

    I’m still new to OCD – my 13 year old daughter was just diagnosed and although I think she has had it for a long time, her compulsions seem to be getting worse. She is working with a therapist but is just in the beginning stages. My question is what parents should say about a compulsion. My daughter is afraid of germs, sometimes won’t eat for fear of getting sick, and is afraid to fall asleep at night, to name a few of her compulsions. We are not doing ERP at the moment as really she is just learning about OCD and how it affects her. Even though I understand that people can learn to deal with OCD, I feel so helpless right now. Anything I say seems to hit a brick wall in part because she doesn’t yet feel empowered to fight it. I’m just trying to figure out how to both be empathetic to what she is dealing with while at the same time not enable the OCD. This might not be the discussion venue for me question but I thought I’d put it out there anyway. Thanks, Laura

    • sethgillihan says:

      I appreciate your comments and questions, Laura–they’re so common and important. Obviously the whole family can be affected by the OCD. As parents we want nothing more than to be helpful to our kids, and it can be so hard to know what to say that will help when a child is struggling with OCD. I like what Janet had to say as someone who’s been down this road with a child of her own. As a therapist I find that it’s really valuable for family members to hear from the person with OCD what would be helpful when he or she is being bothered by obsessions and needs to resist doing a compulsion. It may even be especially important with teenagers to enlist their help in letting family members know how to be of help, and what kinds of comments are likely to just be frustrating. Before a person has the tools to fight back against OCD it may be especially hard to find ways to be helpful. In fact, even the person himself or herself very likely will not know what would help! A therapist who is an expert in dealing with OCD usually can provide guidance in these matters, both in terms of the treatment itself and in terms of family involvement. Thank you for sharing what you’re going through, which again I would say most parents of kids with OCD experience.

  19. Hi Laura,
    I’m so glad you commented and I’m sorry to hear things are rough right now for you and your daughter. There truly is hope for all OCD sufferers, no matter how helpless you feel right now. You are both learning about OCD and getting her help at a young age is a huge plus. While I am not a therapist and maybe Dr. Gillihan can answer your question in more depth, I will say that what helped us a bit in dealing with my son was always being sure to separate him from his OCD. So if you are angry or frustrated over the situation, that’s okay, as long as your daughter realizes that it is the OCD that you are upset about, and not her. This approach also helped us to not enable him, as he understood we weren’t going against him, but rather his OCD. Good luck on your journey. Your daughter is lucky to have you. I hope to hear from you again.

  20. Jay says:

    Hello!

    I think the article give really good explanation of the standard ERP . Which mean to believe your obessions may be truth or may appear and If you resist your compulsion , you may discover that the consequence will probably not happen…That said , the part where you say that repeating yourself ”its only ocd” don’t work is wrong and I think therapist should be very careful about this. Sure if a person with ocd don’t have any knowledge about the disease , is all stress out and keep repeating to himself every 5 seconds ”ITs only ocd , its only ocd , its only ocd , its only ocd…” that WONT work….But someone who read about it , understand it and realised that you don’t control your thought but you have control on the way you react to them , CAN just relax when he feel a obsessions comming and say ”look its probably just my ocd , theres no reason to believe im gonna hurt this guy” and move on..If you look on the internet you’ll find a lot of studies suggesting individual Cognitive therapy is equal or better than individual ERP alone .Finally my point here is not to talk bad about ERP , exposure response prevention therapy work wonderfull and cognitive therapy work for a lot of people too!

    Jay

    • Thank you for your thoughtful comment, Jay, and I understand what you are saying. I think Dr. Gillihan’s concern over saying “it’s only OCD” is that it will indeed become a ritual, but I don’t want to speak for him, and you certainly make a good point. I look forward to his reply to your comment!

      • Jay says:

        Yeah Exactly Janet . I also think thats what she means ! My point here was that it seems for a lot of Therapist comming from the ”Classic ERP School of thought” difficult to believe that ERP only ”MAY” not truly be the best treatment for a lot of patient .ERP ruled the ocd world for decades but if you look around things begin to change . When I talk with therapist few and few suggest to their patient to believe their obsessions maybe true as a way to resist compulsion/ritual. A lot of people found difficult/impossible to believe they MAY or MIGHT hurt their children . If they learn and read about ocd , they can after do exposure but the patient now know that these urge/thought or ”only ocd and that thought dont mean action” I completly understand why these ERP therapist find these hard to believe because this is not what they learn , so its complety normal. I myself , suffered from OCD and IBS ( irritable bowel syndrome) , it took therapist 20yearss to accept that IBS CAN be cure with hypnotherapy . Im not sating hypnotherapy as something to do with treating OCD its an example..I myself (cognitive background )find hard to believe that a ERP therapy without A LOT ( not a lil bit) of cognitive reconstructing , nutrition tips , training tips , positive motivation Can be beneficial in very longrun . I saw a lot of people getting BETTER with ERP alone but rarely saw someone really free from ocd with ERP ( they feel way better but not free) because they did not learn enough about anxiety and whats create it …

        Finaly like I said previously ERP and CT are both good , some therapist combine both and it seems to work well!!

      • Yes, thank you for your thoughtful and thought provoking messages, Jay. I’ve found that in ERP there tends to be a progression in the person’s stance toward the thoughts. Initially it can be crucial to expose oneself to the possibility that one’s obsession-related feared consequence might actually happen. After the acute treatment phase the eventual goal generally is for the person to be able to ignore the voice of OCD if it’s still there to some extent–to treat it as a “noisy neighbor” as we sometimes say. As far as other therapies, there are all kinds of treatments that different people have found useful. When it comes to recommending a first-line treatment, though, I have to rely on what the best studies to date have shown. And of course as clinicians we have to be open to learning about new treatments that might be better than the old ones, or might be more helpful for some people.

        Thanks again for your thoughts!

  21. Brandon says:

    Hi Dr.Gillihan

    I’ve been suffering from Pure-o recently . I read your article as long with couple ERP books . I think I understand ERP pretty well ( expose and when you feel an obsessions comming , feel the anxiety , DON’T try to relax and resist the compulsions) . The thing is i’m having Panic attack also and sometimes problem having bowel mouvement ( because of anxiety , not because of my nutrition) too . When I feel an attack comming or I try to have a bowel mouvement , I just try to relax , stay positive and everythings usually go well…But what Do I do when I have an ocd obsessions in the same time of an attack or feel having
    bowel mouvement . Ocd ERP treatment say not to relax when feeling obsessions and panick attack treatment and constipation treatment say to relax.Can I just ignore my
    obsessions an relax for 5-10min in my day to pass over a panick attack or having a bowel movement. I feel like if im having more and more panik attack and constipation it will only make ocd treatment much more dificult – impossible .

    Thanks

    • sethgillihan says:

      Thanks for the question, Brandon. While I can’t speak specifically to what would be best in your situation, you raise a really important point about the place for relaxation in ERP. Research studies have shown that relaxation by itself generally is not a useful way to treat OCD. At the same time, I think there is a place for relaxation in the course of OCD treatment. ERP is hard work and requires a lot of time and energy. For that reason, it can be really valuable for a person doing ERP to find times to try to enjoy some down time. While ritual prevention needs to continue all the time, a person can take a break from exposures. For example, after a rigorous session of exposures with a therapist and/or practicing exposures on one’s own, I usually encourage a person to find a way to unwind–watch a movie, relax with friends and family, and so forth. Ideally these activities allow the person to “recharge his/her batteries.” In the meantime the brain will continue to process and consolidate the important learning that is happening through the exposures.

      Thanks again for the question and I wish you all the best!

  22. maramaz says:

    I feel as though I have a hyper-sensitive Amygdala that is constantly probing my thoughts looking for anything to cause a spike or reaction.

    Over the past 6 months this has been found in the form of repeating song portions for days and sometimes weeks at a time. It’s either a catchy portion with no lyrics, or lyrics that I don’t completely know by heart, and until I can fill in those blanks with the actual words, they are just repeated. Eventually, after several days, the obsession with the song portion gets to me and I have a reaction by the Amydala, which only makes it stay longer.

    I’ve read about both ERP and mental compulsions. I have been doing ERP for 6 months as well with songs. I sit and run various offending portions from the past several months back, and let the anxiety levels spike, and write down the results, etc. This doesn’t help as much as I would like as it just seems to only be a formal exposure for what I’ve been having informally for hours per day, for weeks? In other words, am I not exposing myself to the repetition all day long already. I can’t seem to come up with a mental ritual compulsion either?

    Trying to not think about the song portion doesn’t work of course and that would be a compulsion anyways, so I quit trying that technique for any thoughts years ago as I want to confront them and let them play out. It’s just that these song portion thoughts will play out for so long I eventually get the spike anyways.

    For me, it’s like having a slow water drip on your back, how long are you supposed to be capable of rationally and successfully ignoring it before understandably succumbing to it? Unfortunately, there is little info on ocd and song portion obsessions. They are acknowledged to exist (earworms), but there is little on therapy when they cause spikes.

    • Brandon says:

      I would also like to have your opinion on my ERP treatment . My therapist gave me homework asking me to agree with my thought .You suggest about the samething in your text ( ”Im friend with the devil” ”im a devil worshipper”) but you also told to a member (mike) not to answer with statement like ; Yes im gay or yes im a killer. So im wondering if you just change your point of view on this or Im not understanding ..because my therapist told me to react ( I have religious ocd and killing thought )with statement like ”Yes im a psychopath” and ”yes im friend with the devil ” … And second the text you wrote is that for homework or in a session with a therapist ?

      Brandon

    • Thank you for the interesting comment and questions, maramaz. I’m sorry to hear about the irritating earworms. While I can’t say for certain what would be helpful in your specific situation, you raise some very important issues about what’s not helpful in responding to them. In particular, trying to push them away generally only strengthens them. In general the recommendation is to not only allow the song to be in one’s head but to consciously try to keep it in mind whenever one realizes s/he has stopped “hearing” the song internally. Over time the songs tend to lose their grip on us if we try to keep them in mind.

      • maramaz says:

        Dr Gillihan, thanks for the reply. I”m open to just about any suggestion for future relief. I’ve been on various meds for PD for 20 years. I weaned off Paxil after being on it for 7 years (I was doing great, best I had felt in those 20 years, but I didn’t like what I was reading about Paxil and it’s withdrawals, which I did experience. Maybe that was a mistake?). I did a slow taper that took almost 2 years and I was completely off for about 3 months when this latest issue cropped up. I stayed off all meds for 3 months and finally got on zoloft hoping for some relief, which I have got. I do know that when I’m not obsessing over a song or I’ve gotten over my most recent one, that I’m afraid to turn the radio to a music station vs talk radio. I don’t want to hear another potential earworm. That is not the right approach. Should I be exposing myself to music on purpose as well? Maybe listen to random music as part of therapy? Should I also snip the past and present offending song portions and play them back in loops? Maybe go to sleep listening to music? I definitely need to get over the slight trepidation I have of just hearing songs. Any specific OCD Dr’s in Mid-Michigan?

      • Maramaz, it sounds talking with a good OCD doctor, as you suggested, may be a good idea for dealing with the specific issues you raised. The best resource I know of is the International OCD Foundation’s website:

        http://www.ocfoundation.org/findproviders.aspx

        Some of the work in dealing with OCD, and maybe especially with things like earworms, involves learning a new attitude toward the intrusions. Some level of acceptance often is a goal of the treatment, and is something that a cognitive-behavioral therapist is likely well trained to help you address.

        I wish you well!

  23. Thanks for your question, Brandon. My approach varies with the individual. Sometimes the person will say, for example, “I love the devil,” whereas other times it’s more effective to say things like, “Maybe I sold my soul to the devil.” If the person’s anxiety is triggered by agreeing with the thought then that’s likely to be the direction that I’ll use. It’s all about what’s most helpful for the individual. As for the text, I generally develop them in the session with the individual.

    All the best!

    • Brandon says:

      Thanks for the fast reply!

      So is it a good thing to do this at home as a homework ? Did you ever give assigment like this where the client have to completly agree with thought ( ”I love devil” )?

      • You’re very welcome, Brandon. And yes, it can work fine as a homework assignment, too. Again it all depends on the individual, his or her experience with the treatment, and so forth. As for the exposure statements I usually just ask the person which is most upsetting, and then have him or her use the one that seems to really target the obsession. So yes, when agreeing with the thought is the scariest, we’ve gone that route.

        Thanks again for your questions!

  24. Mike says:

    What would you reccomend if the obsessions are different every time? Also, I have panic disorder is there any way to stop me from continuing an attack besides meds and the bag? I’ve only been recently diagnosed but it has caused me to take medical leave from school and work. I’m also starting to have real rituals I’m getting really tired of this….

    • Thanks for your question, Mike. One of the good things about ERP is that once a person learns the principles, they can be applied to anything that comes up. So if the a person’s obsessions switch, the instruction still is to avoid any rituals in response to the obsessions. Exposures will be as varied as necessary, and should include careful consideration of what is at the core of the obsessions.

      As far as panic therapy goes there are very effective cognitive-behavioral treatments that are available. They generally include education about the nature of panic, careful record keeping to identify triggers of panic attacks, working on the thoughts that maintain panic, and exposure to situations and body cues (like a rapidly beating heart) that tend to lead to panic. A person who’s interested in this treatment could look for a therapist who does Panic Control Therapy. The ABCT.org website has a Find a Therapist feature that may be useful.

  25. Dara says:

    Hi Dr. Gillihan, i really enjoyed the article. i spend a lot of time scanning to see if my intrusive thoughts are there, thus finding the thoughts 🙂 is this considered mental checking? if my fear is having intrusive thoughts forever and i am scanning to see if the thoughts are there, should i spoil the scanning/checking by saying “i will have these intrusive thoughts forever.” or should tell myself to stop and i try to redirect my attention? thanks so much

    • Thanks for your kind words, Dara, and I appreciate your question–what an important one. It’s not uncommon for people who’ve been through treatment for OCD to begin to have obsessions about the OCD–a sort of “meta-OCD.” The scanning you described sounds like it could be a form of mental checking. In general what I encourage people to do after acute treatment is to adopt a stance of acceptance toward the possibility of future obsessions. Some people find it helpful to do mini-exposures to the possibility of intrusions, as you suggested, whereas others are able to keep from getting caught up in the “obsessions about obsessions” and redirect their attention to more important things. As I often suggest, a therapist skilled in ERP can be helpful when a person struggles to identify what the best solution might be.

      Thanks again for your interesting question, and all the best to you!

  26. freezer says:

    hello dr , i find your article really helpful , i m man over 30 , and i have story of sexual abused in childhood , my first crisis of what i think now is pure O was at the age of 20 , few months and i forgot about it , after 2 years a second crisis, same thing , 2 years after a 3 rd crisis but it take a year to disappear , and for 6 years i was ok , until a few months a go when a new crisis starts , so i make researches and find that what i have is pure o , and every time is about sexual obsession which is just hell for me
    is that normal that pure o disappear for years and come back , and i do not have access to a good therapist in my country ( not developed country,) so i try ERP by my self , i try to identify the obsession and to increase them and to not go in mental rituals
    it s really difficult ,it s like playing chess with a master , i think that even the thought that my pure o will never disappear and will remain coming back every time is an obsession , and my response is it will remain all my life for every day , i do not care
    one of my worst worry is that the abused had changed me , and i can t have a normal life , woman and children cause i will be always a source of danger for them , , i told to my self , yes i will be a danger and it s not pure o , it s the reality
    really i hope to get my life back , to be able to love and enjoy my life again without fear , but i m confused but the fact that it disappear for years where i m really happy , and that it come backs

    • Thank you for your questions and comments. What you’re describing is by no means unusual, that the OCD symptoms will wax and wane over the years. We generally don’t know exactly what made the obsessions come back but we do know the most effective means of dealing with them, which you’ve described: exposure to the fears and stopping the rituals. By the way, if a person has mental rituals then it would not be pure O.

      I know it must be especially difficult when ERP is not available, as in countries or areas of the US where evidence-based treatment is hard to find.

      There’s a great article on attitudes for OCD recovery by Dr. Michael Tompkins that many people have found to be helpful; there’s a link to it from this blog post: http://sethgillihan.com/attitudes-for-ocd-recovery/

      Best regards to you!

  27. freezer says:

    thanks for your fast reply , i think my mental rituals are avoiding trigger situation , seeking reassurance , looking in the internet , going in mental thinking to prove that these thoughts are not true , of course , there s never a final answer , even i find an answer that make me feel fine , this feeling does not stay for long time
    knowing that pure o or ocd , is a chronic problem make me really sad , not because of me , i accept it , it s not something i chosen,and i have to live with it
    but the fact that it can affect my life in future and my relationship ,it s little scary
    but i have to learn to live with uncertainty

  28. Matt says:

    Here’s my story. I grew up as a happy kid and of course had my ups and downs. I was told I had OCD when I was young but never paid much attention to it. In my early adulthood I began struggling with anxiety over the fear of not really loving my significant other, going to hell, death, and being alone. I used to get such bad bouts of anxiety attacks that I’d actually throw up. It made me feel better but only temporarily. One day I was throwing up and I had the thought of what if I killed myself followed by a brief image of me holding a gun to my head. At this point my anxiety spiked to the point I left my house for fear that it meant I was suicidal. This was about 6 months ago and it seems like the more I try to convince myself that I’m not suicidal and that I wouldn’t follow through with those thoughts, the more the doubt and fear seems to shift and move. I’ve battled with it so long that it has worn me down. Which leads to another fear of “even though people with harm ocd never act on their thoughts, what if you’ve been worn down to the point where you will give in.” Also some side notes, I’ve grown up Christian and have always thought suicide is a senseless act. Before that time when I threw up, I never even had a thought cross my mind of suicide. It’s something I don’t associate with me but it seems like it just won’t go away. I have a lot to live for, great job girlfriend and potential. I’m generally very happy whenever I’m not dealing with these thoughts. It’s affected my life in that I’m afraid to be home alone. I’m afraid to be around guns now ever though I grew up an avid shooter and hunter (suicide by gun NEVER crossed my mind back then). I just want to know what is wrong with me, is it fixable, am I suicidal, and what can I do to improve because I’m tired of wasting my life in fear.

    • Matt: Thank you for your message. Fears of self-harm can be a part of OCD and should be assessed thoroughly with a mental health professional. If the thoughts are based only on obsessive concerns with self-harm then exposure and response prevention can be an effective way to handle them. People who are actually thinking of harming themselves should of course seek appropriate emergency help, by calling 911 or going to the nearest emergency room. I wish you well!

  29. fuzzy says:

    Hi Seth, i have a question about erp, my OCD is about religion. I fear that i might secretly want to be a satanist deep down or that i might be one and just leave my religion. the thing is i went online and tried to research erp therapy and decided to give it a shot, i tried writing the same satan and constantly forced myself to not avoid situations that could spike me and a few other erp methods…its a bit better and my anxiety is much less but now i just did one that i think might just destroy me. i PURPOSELY went and read books about satanism and googled it and read the history and everything and later decided to prove to myself that i didnt want to be a satanist by PURPOSELY googling WHY my religion is ‘WRONG” and why OTHER people dont like it and just about anything to make me HATE my faith or anything to put me off from my faith, just to see that i wont lose my religion. but now i feel so much guilt, because i keep thinking, ‘maybe what these people say is true’. what if i find there arguments valid (which i dont) and do end up leaving?? there is no logic way that i can accept this but what if i purposely DONT WANT to listen to reasoning?? because i dont see the reasoning i give sink in….also im not convinved i have OCD…i still question myself and know that im just faking it or just using what i read about OCD online to make it look like i have OCD myself…i dont know what to do? and the thing is when i do things related to my faith like my prayers, i dont feel anything, nothing and that scares me because what if i secretly gave up my religion and just trying to hide everything…i know OCD mades you think that but it doesnt feel like OCD anymore..it feels genuine. i try telling myself to ignore it and just label it as OCD thought but what if it is GENUINELY me? i feel like iam lying to myself because the anxiety i used to have is not there anymore.

    the last erp session i tried to do with purposely seeking out satanism and why i want to leave my religion (even though I DONT) is haunting me non stop, what if i just accept satanism based on the things ive read? my thoughts already resemble that of a satanist so what if im end up thinking like this forever without any anxiety? im also starting to develop a satanist mentality with pretty much anything…

    i know i screwed up the erp therapy, but is it possible for someone to become what they are fearing? especially in my situation?
    please reply,

    thank you

    • Hi, fuzzy. Thank you for your very well articulated questions and struggles. What you’ve described is so typical of OCD, including the fear (betraying my religious convictions in some way), the interference with one’s faith practice, and the questions about whether it’s OCD or not. Making sure it’s OCD is a common ritual, and OCD wouldn’t be nearly as difficult if it were always easy to tell what it is! Imagine if OCD announced itself: “This is OCD speaking, you can disregard whatever I say.” Instead it masquerades as real danger. Part of ERP can include learning to tolerate the uncertainty of whether something is or is not OCD. From what you’ve described I certainly wouldn’t conclude that you’ve “screwed up the erp therapy,” although I can understand why it might feel that way. I’d say that you’ve reached a point that many people reach in treatment where a difficult issue comes up and at that point the assistance of an experienced ERP therapist can help one to navigate through the stuck point. I wish you all the best in your ongoing recovery.

    • Hi Fuzzy. I just wanted to say that the obsessions (or main obsession) that I experience is very similar to yours. I have a fear of blaspheming the holy spirit and I have thought the exact same, doubtful thoughts as you, within the context of my fear. It always starts with a “what if” doesn’t it?

      I don’t think that I had anxiety at first. I THOUGHT that I had said something wrong during a prayer and blasphemed the holy spirit. And then I eventually was thinking, “I don’t feel guilty, I must have actually blasphemed god. I must not be a Christian anymore. ” So then I obsessed over not knowing whether or not I actually had done something wrong until the OCD grew. I should also mention that I had a hormone imbalanced which made everything 10 times worse. But now here I am getting better.

      I probably would have done the SAME EXACT thing as you, looking up Satanism just to prove my faith or my strength. It must be a good sign if you do not have anxiety, to me that means that you are at the point where you are back at the beginning and much more healthy then before. Why borrow more trouble. I think that if you keep talking with your therapist they will be able to help you lose the worry or simply the obsession again. It might even take the same steps as before. I know this is very complicated because you might wonder sometimes where the line is drawn between what is OCD and what is “my faith.” I just wanted to let you know that you’re not alone and that we will hang in there! You’ve already come so far!!

      • In addition, in times where I have had faith and been truly peaceful I felt like I had freewill and not that every decision could end terribly. I hope this helps in remembering or realizing where the OCD comes in.

  30. fuzzy says:

    hi Seth, thank you for your response. i appreciate it alot.

    i just have one question, you know how i said i ” PURPOSELY googled why my religion is ‘WRONG” and why OTHER people dont like it and just about anything to make me HATE my faith or anything to put me off from my faith ” ,.. well is that what ERP is all about because even though you said i didnt screw up my erp. i keep thinking that what i did isn’t part of ERP and that im finding more proof as to why i ‘should’ or why i want to leave my religion and that the untimate consequence is that i WILL end up beileving all that and eventually leave….i dont know, its crazy but thats what it actually feels and this is reinforced further by my lack of feeling with everything i do and me not doing as much religious things as i used to do before…

    thanks for your wishes and responses and i will make an appointment to see an OCD therapist personally because i don’t trust myself anymore with ERP.
    thanks again.

    • Hi, fuzzy. It’s a great question. The kind of exposures that are helpful depends on what the specific feared outcomes are. Usually the indicator that an exposure is on the right track is that it increases a person’s distress in the short term, with long-term reduction in distress. Seeking out an experienced OCD therapist is a great idea since s/he should be able to work with a person to figure out if the exposures were on target, were too much too soon, weren’t accompanied by ritual prevention, and so forth. All the best to you!

    • Jamie says:

      I would say that if you’re afraid of leaving Christianity, that proves you don’t want to leave it. We humans only fear what we do not want to happen, so if you’re afraid of it happening then you must not want it to. 🙂

  31. Henry says:

    Hello Dr.

    I have a compulsion of counting ( on the road , stairs ect..) But I don’t have any ”fear” or any obsessions about ”something bad will happen” . It seems only like a compulsion and it give me a lot of anxiety if I don’t perform it..Also I don’t see how Normal Exposure can help me because I don’t any obsessions . I don’t count because I think my mom gonna die or anything like that..Any help Dr??

    • sethgillihan says:

      Hi, Henry. Thank you for the very good question. You raise the point that there are compulsions that are driven not by a magical fear that someone will die, for example, but instead the person just “doesn’t feel right” if s/he doesn’t do the compulsion. Needing to have things arranged symmetrically would be another example of a compulsion that sometimes isn’t driven by a fear that some bad event will happen. The feared outcome in these cases could be something like “I’ll always feel distressed if I don’t count.” This kind of OCD can respond well to ERP. I appreciate the question and wish you well!

      • Henry says:

        Thant you for your reply!

        How do you do ERP is this case ? Do I stay in the stairs without counting and wait for the anxiety to drop…or I walk in the stairs ”distract” myself and move on without counting…? And it seems like a lot a person in my position use Cognitive therapy techniques more than ERP ..Is Erp the best traitment for people who do not have any obsessions/fear?

      • sethgillihan says:

        Good questions, Henry. I’d have to actually be working with a person to determine all the specifics of how we’d approach things. As always with OCD we’d want to do the thing that increases anxiety in the short term and not do the thing (avoidance or compulsions) that provides a quick drop in anxiety. In the article we wrote we discuss distraction and when it can be helpful vs. harmful during exposures. For example, if distraction reinforces the idea that “I can’t handle direct exposure to my fear,” then it’s likely to get in the way of treatment success. As far as the treatment of choice, I am not aware of evidence showing that cognitive therapy is better (on average) than ERP for these kinds of issues.

  32. Emma says:

    My biggest fear is that my thoughts are “real” rather than thoughts provoked by OCD. My understanding is that this is very common, and that a good way to know if something is a “real” thought or an “OCD” thought is to notice whether it comes with anxiety or guilt. These thoughts definitely come with anxiety and guilt, but because of their nature (I obsess over whether I “really” love my boyfriend, whether I find him boring, whether I’m actually attracted to him or just pretending, etc.), it seems like I would have anxiety or guilt if they were real as well. Between worrying if I’m pretending to myself that I like him, whether I feel the right way, etc., I’m worrying that I’ve just convinced myself I have OCD because I don’t want to break up with him. I end up asking him whether I sound like people online who clearly have it, for example. It’s somewhat ridiculous, because I can identify someone who “has it” (to my untutored mind) very easily from reading their statements, but even if our situations are functionally identical, my assumption is always that I don’t actually have it, and that I’m somehow tailoring my thoughts to fit what they think to make myself feel better.

    I know you can’t tell me if I have OCD. However, I guess I’m wondering what advice you would give to someone in that situation? Should I first focus ERP on the fear that I don’t have OCD, or should I try to face my fears that I don’t feel the “right” way about my boyfriend?

    Thanks. It’s really nice of you to answer these questions even though the article was posted so long ago.

    • Great questions, Emma, and I’m happy to field these kinds of questions. In the end the goal with this type of OCD (as with any type, really) is to learn to accept the uncertainty that one can never know for certain (100%) that something is or isn’t OCD. In a situation like what you described I would probably include in the treatment exposures about both of the issues that you raised. The following article also might be helpful. It was posted in a thread on OCD as part of a listserv I belong to and includes a discussion of relationship OCD as well as OCD about being gay: http://www.ocdonline.com/articlephillipson7.php
      Good luck with everything!

  33. Nicole S. says:

    My 15-year-old son has been suffering with OCD for 8+ years. He has “pure O,” and his obsessions have ranged from food contamination, disease, random street drugs being forced upon him (we live in the suburbs and he doesn’t go anywhere where this could be possible), stop breathing, heart attack (when he has a panic attack), seizure, fainting, death (of himself and loved ones)… You name it. Over the years he has learned techniques to stop compulsions, which are usually reassurance seeking and avoidance. Three weeks ago one of his best friends committed suicide. The first week he was just ANGRY at her, which we thought was a fairly reasonable grief response. Then his OCD went into hyper-drive. Now he’s having suicidal obsessions as well as fears of family and friends dying, afraid to go to sleep, afraid he’s going to get sick and die, afraid he’s”crazy,” and a few others all at once. We haven’t slept or had much peace in two weeks, and I fear that because he is having so many different obsessions at once, this may last longer than usual. He sees a psychotherapist weekly and I just called and left a message for an OCD “specialist” that I found on the OCD Foundation website, so hopefully she gets back to me quickly. Is there anything specifically that I can do for him in the meantime? Although I know not to give into his reassurance seeking, I am finding it so difficult right now because he is so fragile and afraid. It’s like we’ve both forgotten everything we’ve learned over the past 8 years.
    Thank you!!!!!

    • Hi, Nicole, and thank you for the questions. I’m sorry for your son’s loss and for the turmoil that your family is experiencing right now. Seeing an OCD specialist as soon as possible certainly sounds like the right course of action. Although I can’t give specific recommendations, there may be times when the best a family member can do is to be with their loved one and be as supportive as possible. Before treatment starts that support might include reassurance, even though we know that the rituals will have to stop for the person to recover. In treatment the therapist can work with the OCD sufferer to stop the reassurance seeking in a way that’s not overwhelming. By the way, you mentioned “pure-O” and then described rituals (like seeking reassurance), so I’m wondering if maybe it’s not purely obsessional OCD. It’s an important point because there almost always are rituals (often mental and thus invisible), and they’re the “horse that pulls the cart of OCD.” I hope that your son is able to get the professional help he deserves as soon as possible, and I wish your family all the best.

      • Nicole S. says:

        Thank you Dr. Gillihan.
        He has been in treatment since he was seven. The first doctor, who diagnosed him with OCD, did CBT & ERP with him starting at eight years old. We moved from NY to FL a few years ago, and it was a doctor in St Augustine that told us he was “pure O” because all of his compulsions are are thoughts rather than physical acts. (She also wanted to put him on anti-psychotics. So glad we listened to our hearts and went elsewhere.) I can see the point that your making & it does make sense.
        We moved back to NY and he’s been seeing a psychiatrist for medication management (celexa since 8yr’s old) and a psychotherapist weekly for therapy, but I think he does mostly talk-therapy, that’s why I went to the OCD foundation site to find someone who specializes in OCD. As I said in the earlier post, he usually uses a lot of the tools that his first doctor taught him years ago (unfortunately she had moved to Colorado while we were in Florida). I think it’s just the nature of this last trigger (his friends’ suicide) that has made his obsessions blow up to such a degree this time.
        Thank you so much for your response.
        Also, I bought a book recently called “Talking back to OCD” by John march. I gave it to my sons therapist to read so that we can start to use it with Tyler’s therapy. Have you heard of this book and do you think it’s a good idea to use it?
        Thanks again!!!!!!!

      • Sounds like it’s good that you followed your intuition and looked for a doctor who had a better understanding of how OCD works. The book by John March is supposed to be really good. I usually advise people to be careful, though, about working on ERP with a therapist who hasn’t been thoroughly trained in that approach. While the principles are straightforward, there are many mistakes that are easy to make when first starting out (which is why we wrote the article on common pitfalls in ERP). If the therapy isn’t delivered effectively and the person with OCD therefore doesn’t make much progress, it’s easy for the person to conclude that “I tried ERP and it didn’t work.” It’s not uncommon that I’ll work with someone who tells me that they “did ERP,” and when they describe what they actually did in the treatment it’s obvious why they’re still suffering. So I think your choice to seek out an OCD specialist is a wise one.

  34. Jocelyn says:

    Hi. My problem is not that my thoughts are about things I am afraid I might do, but they are just gross thoughts that make me sad and cry or disgust me to my core. It bothers me. Thinking the thoughts on purpose, horrible thoughts about people I love, doesn’t seem like it could work for me. Because when I accept the thoughts, I don’t feel anxiety but I still feel guilt and sadness. Any help for me?

    • Hi, Jocelyn. I really appreciate the question. Disgust is very common in OCD, as are feelings of guilt and sadness when people imagine inviting in terrible thoughts about their loved ones. Since these thoughts and feelings are common in OCD, experienced OCD therapists will have worked with them and should know how to help, including ways to address the guilt and sadness you mentioned. So yes, I would think that your odds are very good for being helped by good OCD treatment.

  35. Dasa says:

    It is great there are websites like this one – it really helps me to understand the background of this disease.

    I have been suffering from OCD for 20 years, 10 years in (a pretty successful) therapy. I have learnt a lot and can manage most of day-to-day obsessions (in fact I had even long spells without any obsessions) – I do not give in to compulsions and wait for the anxiety to pass. BUT (there is always a but I guess…) I do not know how to handle two events that happened a long time ago – one has actually triggered my OCD (it was the first time it happened). Both are (as all of my obsessions) related to fear of harming other people because I have done something I should not have done.

    The problem is that during my worst phases I have made the mistake of asking/seeking reassurance/searching on the internet and as any person with OCD I found what I was looking for – a possibility that something might have actually happened. I am trying to accept that I will never know for sure, I do not let this anxiety to invade my life, I really do – but I still feel I do not know how to face these two situations properly. It happened 20 years ago when I was 10 and I spent 10 years caught in doubts, then spent too much time trying to make sure nothing happened. I do see the same pattern of my obsessions, but I still have a problem to accept that the first time it happened was OCD as well. Most of the time I believe that this extreme anxiety I experienced when 10 and the doubts triggered OCD and its obsessions that do forever copy the pattern of the first experience. Anyway… how can I face something that is history and that I have so over-analyzed before I knew that analyzing does not help at all?

    Should I simply accept that I will never know for sure, that although there is a possibility that something might have happened no “normal” person regards it as significant enough? Is this the way? To accept uncertainty, accept one’s mistakes, accept possible consequences and to learn to let go, to forgive oneself, to learn to assume responsibility only for things that actually happen and not for those that could maybe, possibly, theoretically happen if…if..if….?

    I do feel I am missing one or two pieces of the puzzle to make the picture click, fall together. Appreciate any ideas/hints which way to take. Dasa

    • sethgillihan says:

      I appreciate your questions and comments, Dasa. Living with that uncertainty is the ultimate challenge–to accept not knowing. In ERP we often explicitly ask people with OCD to imagine that the worst feared consequence has happened, and to become more tolerant of the bad feelings that come up. This approach is the opposite of what OCD pushes us to seek–rather than assuring that nothing bad happened, we work to live with the possibility that perhaps something terrible did happen and that we’re responsible. Over time the upsetting thoughts tend to lose their power to terrify us when we stop fighting them. All the best to you.

  36. Austin says:

    How would you do the opposite of what ocd wants, if you have sensorimotor ocd. I am always trying to decided if I should or should not swallow, blink, etc. and am always questioning if my decision was a compulsion. In my head I am always wondering should or shouldn’t I do something.

    • sethgillihan says:

      It’s a great question, Austin. One of the things that can be helpful in this kind of OCD is for a person to work in therapy on the feared consequence. For example, in some cases the fear might be that one will always have indecision about performing the action. Imaginal exposure can be used to get over the feared consequence. In vivo exposures for sensorimotor OCD typically involve focusing on the distressing sensations until the discomfort subsides. Janet has written an excellent post on this type of OCD (https://ocdtalk.wordpress.com/2013/10/27/sensorimotor-ocd/) and links to Dr. Steven Seay’s articles on the topic, so I won’t repeat what they’ve written. The good news is that ERP can be very effective even for this “flavor” of OCD! Thank you for your question.

  37. Zelazno says:

    Hello Dr. Steven Seay i’ve been dealing with Pure O Ocd thoughts since i was 7(i’m now 20);It got severe when i was around 17. I went a whole night without sleeping and then a horrible intrusive thought popped up: What if if every time i try to go to sleep i wake up and never get to sleep. This obsession gave me extreme anxiety;I went more than a month without getting a good night’s rest because that thought popped up every time i tried to sleep.I finally got over that obsession but a new one emerged. What if i accidentally trade my sou for something i want like getting rid of these obsessions. Every time i had this thought i would go through compulsions thinking to myself repeadetly “I’ll never sell my soul”. This went on for a while. Later that year i found out about Pure o. This gave me great relief. I was doing great for about 5 months. I didn’t have obsessions anymore. But now im afraid me getting better was because maybe the trade did happen. Please help, this thought gives me daily stress. I can’t concentrate in college because im constantly ruminating trying to prove myself i didn’t. Thank you…

  38. Zelazno says:

    Oops Sorry i got your name wrong Dr. Gillihan

    • sethgillihan says:

      No problem, Zelazno, and thank you for your question. What you described is very typical of OCD that involves primarily mental rituals. In your case you described telling yourself things repeatedly to try to reassure yourself, trying to prove you haven’t sold your soul, and so forth.

      ERP handles these kinds of rituals just like any other kind–they have to be eliminated. As always I know it’s easier to say that than to stop them, which is why many people find it helpful to seek professional treatment as part of their recovery. It usually takes creativity to learn ways to interrupt the mental rituals, which can be automatic.

      Once we’ve broken the cycle of obsession-compulsion, the thoughts that trigger obsessions tend to not be so upsetting. A person can even learn to say, “Well, maybe I *did* sell my soul,” and not feel upset. We can never really know anything for sure, and ERP helps a person to live with that uncertainty.

      By the way, I think it’s important to point out that “Pure O” technically refers to someone who doesn’t have any compulsions, and I’ve almost never heard someone describe themselves as “Pure O” without then going on to describe their mental rituals.

      I think it’s more than a technical point because it underscores that this kind of OCD (involving all or mostly mental rituals) is not fundamentally different from OCD with more overt rituals. We can understand the relationship between the obsessions and the mental rituals, and design ERP to treat this form of OCD.

      I wish you the very best.

      • Thanks so much for this great explanation, Seth, and also for clarifying “Pure O.” I agree it’s very important for those with mental rituals to realize their OCD is also treatable with ERP therapy.

  39. Great post. Unfortunately, though, my efforts to counteract my religious obsessions have resulted in my having to “throw out the baby with the bathwater” and abandon religion almost completely. This, I am told, is a consequence of black-and-white thinking, which I am aware of and try to counter with self-awareness and self-talk (“this is black-and-white thinking; where are the shades of grey?”) whenever I catch myself. But it’s much harder than, say, limiting checking that the door is locked to twice instead of five times, because religious ideas are more tied into reward and punishment. As in, my prayers are not being answered because I didn’t do them well enough, so in order to get the reward and avoid being punished for not being good enough, I have to do prayer more and better and more precisely….it can drive you crazy! So even though I miss my religious devotion, I find myself much less anxious and tense by just letting it go, and of course my OCD would like me to let it go completely but I have set limits on that, and have identified specific observances that I do in spite of a bit of anxiety, because they make me feel good when I do them. And I have to remind myself that God made me the way I am, and therefore God must not want me to get all that granular about religious observance.

    • sethgillihan says:

      Thank you for your comments, Laura. It sounds excruciating, the struggle with those thoughts and doubts and fears. It also sounds like you’ve done some hard work to push back on the OCD. I appreciated your comment about God’s not wanting you to “get all that granular about religious observance”–well said! I wish you all the best.

  40. Zelazno says:

    Thank you very much.

  41. Thank you so much for this!! I also have religious based obsessions. I think the kind of compulsions I experience are categorized under “Obsessional Slowness” so I will end up doing things like making my clothes sit perfectly on the hanger when I put them away.

    BUT mostly I have mental compulsions and it is harder to follow the plan in the “OCD Workbook” that I am working through and make a list of compulsions and hands on ways to address them. Your suggestions for responding to fearful thoughts are brilliant. I recently tried responding to fearful thoughts by saying “maybe that’s true…” and I felt it was very effective.

    I have a very specific question though. I have a specific fear of blaspheming the holy spirit (part of the biblical trinity) because it is said to be the unforgiveable sin. From what I understand, if I were to believe, in my heart, that the holy spirit was evil that would guarantee my damnation. Could you give me one example of what to say aloud to stop the mental compulsions? I am in the process of getting a new therapist. There are not qualified enough to treat OCD within my insurance plan but I am intending to have the therapist follow the “OCD Workbook” with me.

    • sethgillihan says:

      Thank you for the question and the kind words, Epiphany Laws. It’s a great question about blaspheming the Holy Spirit, and I believe the passage in question is from chapter 6 of the book of Hebrews.

      Not surprisingly, OCD goes after something very frightening, in this case the fear of eternal damnation as a result of unforgivable blasphemy. As with any form of OCD, ERP would encourage the OCD sufferer to do the opposite of what OCD demands. The particular exposure will vary from person to person; an example might be, “It’s possible that I’ve committed the unpardonable sin.”

      I wish you the very best in your treatment and as you get a new therapist.

    • Jamie says:

      Hey, I don’t know if this will help because I know OCD tends to have difficulty with any ambivalence…I have always believed that blaspheming the Holy Spirit is basically telling God to f**k off and leave one alone for good. (And feeling no fear or anxiety or guilt at all in doing so!) thus rationally speaking, your fear of doing so proves that you have not (and will not) commit the unpardonable sin. Perhaps that can help as a cognitive, belief-challenging tidbit. All the best.

  42. Sam says:

    Wow, what a wonderful article. I wish i found janet and dr Seth’s article earlier.

    I have ocd ( but im having trouble accepting it) and my biggest problem is checking if doors are locked, computer turned off, stove off, car lights and locks, checking if phone call properly ended, if i cleaned myself properly in shower..etc. I been doing treatment for 5 yers but i just learned about erp about a year ago. I wasted so much money but im glad finally i found it.

    My question today is about the erp. Is erp appropriate for checking over and over if things are locked or off?? And for germs and contamination fear, still erp?Sometimes i mentally repeat/redo my actions or behaviour like per example i will redo the scenario mentally (after its done) like me locking the door or me checking the floor if i havent dropped anything, or redoing a work task mentally and so on…

    And does medication help while doing erp?

    Please let me know what you think about this mess. Im only 28 and im currently screwing up my work and school.

    Thanks in advance.

    • sethgillihan says:

      Thank you for your comments and your great questions, Sam. ERP is appropriate for all kinds of OCD, including the types you asked about. Effective response prevention would include stopping both the overt rituals (like checking a lock) and the mental rituals (like mentally redoing a task).

      There are medications that some people find to be effective for treating their OCD, especially high doses of SSRIs like fluoxetine (Prozac). Many people are able to successfully treat their OCD through ERP without medication.

      As you suggested, OCD can get in the way of all kinds of things like work and education. I do hope you’re able to find relief soon.

      • Sam says:

        Thanks for the advices. I am relieved that i can overcome ocd without medication.

        One things thats been bothering me since long time. Do i have to accept the fact that i have ocd and fight it or should i deny it? I have trouble accepting the ocd because it makes me loose interest in life because of everyday task seems harder and endless while my friends are enjoying life and i cant.

        Another problem here in canada, the psychologists arent trained properly to treat ocd. I am getting treatment since 2009 and i still have no control over my ocd but its better than before. I consulted about 4-5 different but finnaly found one thats not bad but still wondering if im on the right path. If you dont mind, can you give me sites or article that shows how erp is done properly?

        Thanks again for your precious time. Really appreciate it.

      • sethgillihan says:

        My pleasure, Sam. Generally it seems to work best if we acknowledge that things are the way they are. So if a person has OCD, it’s probably better to recognize it for what it is. Once we’re honest with ourselves about our situation, we’re in a better place to do what we need to do–for example, get treatment. We can also begin to question our assumptions (often with the help of a therapist) about what our condition means for our lives. For example, does having OCD mean that we can’t enjoy our lives the way others do? Countless OCD sufferers would say that in fact they find great meaning, pleasure, and purpose in life.

        I’m glad you’ve found a therapist who can treat OCD. There are lots of sites that describe good ERP. Here’s an article you might start with, about common mistakes that therapists make in treating OCD with ERP (which we call “EX/RP” in the article).

        http://sethgillihan.com/wp-content/uploads/2012/08/Gillihan-et-al.-2012-Common-pitfalls-EX_RP-for-OCD.pdf

        Best regards to you.

  43. Charles says:

    Hello Seth !

    I have a question regarding ERP . While im doing my exposure , is my anxiety is supposed to decrease ”by it SELF” if I do not use any Self reinssurance OR I Most use cognitive interventions to lower my anxiety..? I mean if I fear contracting HIV after touching a door . Can I just tell my self ”Maybe i Will contract HIV” and the anxiety Will go down eventually or I must tel my self ”there 99.9% chances i Will not contract HIV” to make my anxiety goes down…?

    • Hi, Charles. It’s a great question. Anxiety typically will go down all by itself if we stay in a feared situation and don’t ritualize. The idea that we have to *do* anything to “make our anxiety go down” is a lot of what keeps OCD sufferers stuck in the cycle of obsession-compulsion. The “Maybe I will…” strategy is what we do in ERP. The problem with saying things like “there’s a 99.9% chance I won’t get HIV” is that for most OCD sufferers, that 0.1% (or whatever) chance is “too big.” OCD hates uncertainty, and so usually will seize on even small probabilities.

      I actually would call the latter response “reassurance,” and not a cognitive intervention. I’d think of a cognitive intervention as saying, for example, “There’s a very low risk that I’ll get HIV from touching the door, and it’s certain that continuing to listen to my OCD is ruining my life. So I’m going to choose that low risk, vs. the certainty of letting OCD destroy what I care about.”

      Thanks for your question!

  44. Greg says:

    Dear Dr. Gillihan,

    It makes sense to me that if one suffers from ‘pure-o’ OCD, one shouldn’t attempt to “fight” one’s intrusive thoughts; rather, one should “agree with them” and simply allow the resulting anxiety to do its thing (however uncomfortable this might be).

    I suffer from harm obsessions, however, and agreeing with harmful thoughts is extremely difficult. E.g., I have recurring thoughts about harming a loved one, and recently, out of the blue, the following thought popped into my head: ‘I’ve decided to kill her.’ How does one agree with that? Instantly I began fighting the thought and reassuring myself that I would never do such a thing.

    I know that’s the wrong strategy, and, as expected, it simply made things worse, so recently I’ve tried to accept some of my most terrifying thoughts. The anxiety was overwhelming, however. I couldn’t help thinking that if I agreed with the thoughts, I would be agreeing to do the harmful thing (and hence be more inclined to do it). Is this something any of your patients have experienced?

    __._,_.___

    • Dear Greg: Thank you for your excellent questions. First I should point out that what you’re describing is often called “Pure O” but there really are compulsions present, too–they just aren’t the kind that can be seen. As you’ve experienced, giving in to urges to do the compulsions just makes it worse in the end.

      The fear that you described is extremely common in this form of OCD: “If I agree with this thought, then maybe I’ll do the thing I’m afraid of!” Generally we work up gradually toward progressively harder exposures, since as you found out it can be overwhelming to do the really hard stuff first. It can take creativity to find ways to make the exposures more tolerable at first. People with OCD often find in treatment that they’re able to go through more distress than they thought they could. I’ve seen so many people find the strength to push through their OCD to get to a better place.

      I wish you the very best.

  45. Brett says:

    Greetings all….I JUST started doing ERP this afternoon. About a week ago I made a decision that I would no longer accept the cell that OCD has helped to put me in. I purchased several books on the subject and after much deliberation (and obsessing…who’d of guessed??) I just dove right into contaminating the hell out of my home. I didn’t feel overwhelming anxiety but is was challenging to be sure. I did this for about an hour. I tried to maintain mindfulness and keep myself focused on the uncomfortableness (in the moment if you will). I found this a greater challenge. For so many years I’ve just come to accept the many, many mental compulsions that I perform every minute of every day that it was almost impossible to keep them from popping in. I’m of course, terrified of not doing the therapy correctly and want my effort to be as constructive/effective as possible. I’m probably being a bit hard on myself considering this was my first exposure, but to “counter” the mental rituals I would repeat out loud “I’m contaminating my home!” trying to stay focused on how that’s an uncomfortable scenario for me. Does this seem appropriate or might there be something else that would prove more effective? I also bought sticky pads and wrote words that cause me distress when seeing them and posted them all over my house. I went to several stores and returned home without washing my hands or changing out my contaminated “outside” clothes for clean “inside” clothes (which I haven’t done in…a year…maybe?!) and licked my hands. Ha.

    I have a lot of work to do but I can honestly say that even though I’m currently uncomfortable with knowing that I’ve soiled my safe zone, I feel a slight liberation. I know that tomorrow when I wake up I won’t have to perform my usual morning rituals to avoid contamination because I, and everything else, are already contaminated! Ugh. Any thoughts on the matter of mental compulsions (which are more frequent for me than physical rituals) when doing exposure would be greatly appreciated. Thanks in advance!

    • Wow, Brett, you certainly sound committed to defeating your OCD. Good for you! I’m guessing Dr. Gillihan will comment on your specific questions. Sounds to me as if you are doing an amazing job so far!

    • sethgillihan says:

      Thank you for your comment, Brett, and I second Janet’s comment about your resolve to get you life back. In terms of handling any mental compulsions when doing exposures, the goal is to confront the feared consequences head-on. So in exposure we identify what we’re afraid will happen and then say to ourselves that those things *will* happen because we did the exposures without doing rituals. Sometimes we’ll say that the scary thing “could” happen or “might” happen–whatever statement activates the core OCD fear. Agreeing that bad things could happen can be a very effective way to interfere with the mind’s attempts to do mental compulsions. You also raise an important issue about the pace of treatment. Usually it proceeds gradually, but if a person can tolerate going “all the way” right away, that approach can work, too. All the best to you!

  46. Brett says:

    Thank you both for the fast replies…it’s appreciated.

    I will use your suggestion, Dr. Gillihan with regards to combating the mental compulsions during exposure. One interesting thing that I’ve noted in the short time that I’ve done the exposures is that now that I’m doing them I’m already engaging in activities that I would have previously avoided… and in doing such I’m actually being exposed to OTHER anxiety-inducing items/scenarios throughout the day. It’s kind of like getting extra exposure in without doing the self-appointed exposure sessions.

    For me I’ll admit that I chose to go into this head-on and fairly aggressively. I was really ready to fight back. I wouldn’t have chosen something that I didn’t think that I could handle, though. My primary guide was Jonathan Grayson’s “Freedom From OCD” but since discovering this site I have read up several of Dr. Gillihan’s articles and have found them very informative and useful as well. I’m thankful for people like you and the work that you do.

    One additional question: how long (generally) do you recommend working through a particular exposure before moving on to another different/more difficult “contaminated” item/situation (a week or two)…and once a new exposure is undertaken is it a good idea to continue incorporating the older one in addition to the new one?

    Thanks very much!

    • sethgillihan says:

      Grayson’s book is a great resource. It’s a good question about how long to work on an exposure item before moving to more difficult exposures. Generally I recommend staying with it until anxiety is significantly reduced, and returning to it on subsequent days to make sure the brain has learned not to be so afraid of the situation or object. Sometimes there can be a temptation to “sprint” past the anxiety and say, “All done!” when we actually need to spend some more time with an exposure. I like a person to get to the point of boredom with an exposure before moving on!

      Once we’re working on higher items we don’t have to keep doing all the lower ones–eventually there just isn’t time in a day to do all exposures simultaneously. And of course we keep doing ritual prevention around the lower level items, even if we’ve left behind the formal exposure exercises. I hope this helps.

  47. Anon says:

    You’re talking about living with uncertainty but trying to accept that you might actually be/desire what you abhor the most is quite difficult and makes you not want to live with yourself. I guess I don’t get how someone is supposed to live with the possibility of having done something awful in the past?

    Other than this, can you tell me more about intention/motivation checking? Is it basically doing something, an act you might’ve done many times before but this specific time, seconds/hours/whatever later having the thought that you did it because what your intrusive obsession thoughts are about is true. (e.g. a mother with POCD wondering if she changed her baby’s diaper because it needed to be changed or because she wanted to see his genitals, and just not being able to convince herself of the former & having vivid thoughts that she pre-meditated it and did actually want to see the baby’s genitals and just going back and forth over this)

    • sethgillihan says:

      You raise an excellent pint, Anon. In order to accept and live with uncertainty, generally we need to have a *reasonable* degree of certainty about the outcome. For example, we may fly on an airplane even though we know there’s some risk involved; if we thought that crashing was a 50/50 risk, we’d be foolish to take that gamble. In OCD it often can feel like there’s a 50/50 (or even greater) chance that the bad thing we’re worried about can happen. Considering the actual odds of what we’re afraid of can help us to adjust our estimates of how likely harm really is. For the vast majority of people, adjusting those estimates won’t be enough to recover from OCD–it will simply be enough to decide to take a reasonable risk and do the exposures and stop doing compulsions. It’s the exposure and ritual prevention that will lead to recovery. So we might think of the more cognitive-type techniques as being the road that leads us to the bridge, with the bridge being ERP. It’s that bridge that will then carry us from where we are to where we want to be. As someone very wisely said to me recently in the course of treatment, “The only way to know is to do it.”

      The intention or motivation checking you mentioned is as you described–questioning and reviewing whether I did something for the “right reason.” It can be treated effectively through ERP. I wish you the best.

  48. Christine says:

    I have 3 questions, but hopefully they are simple ones, and thank you for responding to all these questions so graciously.

    How common is it for OCD, which was mild for years, to suddenly kick into high gear with puberty? My 13-year-old son had it mildly since about age 8, but after falling out of a tree in August 1014 and suffering a concussion, it kicked into high gear, but this also coincided with puberty being well under way. Can concussion make it worse, or is it more common for puberty to make it worse? I ask because my 11-year-old son also has it mildly, and my girls, ages 6 and 8, are showing early signs. Should I expect them all to experience changes in their puberty, with their OCD (or anxiety)? The only relative with OCD is the paternal grandfather & paternal nephew, but anxiety (GAD) runs on the maternal side.

    My older son knows a lot about OCD now, thanks to both of us going over therapy techniques we learn through reading (hard to find good therapists here who take our insurance), but his anxiety threshold is so high he can’t seem to remember the techniques when he needs them, and he often needs me to remind him of the techniques. For example, I hear him in another room telling himself that no, he is not for Satan, he is for God. He shouts his rituals out of frustration when he is at home, upsetting all of us because we can’t escape the stress of what is now moderate-severe OCD. I am often desperate for the noise level and angst level to decrease, so I will remind him of a technique we went over: to say the opposite, for example (Say, “Yes, I might be for Satan”).

    He does his rituals incognito when outside the house, but at home he is very loud about them, which either indicates how high his anxiety is, or that he wants sympathy as he handles something so difficult (I don’t know which). I agree he deserves sympathy, but at some point he has to care about what the rest of us endure. If someone suffers severe headaches, for example, should they go around sharing it constantly so that everyone is brought down, or try to handle it without a lot of fanfare? I want to support him (we all do) but at some point we all have to protect our own health as well–especially since most of us have inherited some level of anxiety ourselves–and I want him to try to take some responsibility for how obnoxious he is when he is suffering (shouting, crying loudly, coming to me frequently with his angst, interrupting family devotions constantly with his loud rituals).

    A side note as to severity: He still has some time each day where he can play outside, play games with siblings, etc, and feel happy, so his quality of life is not all bad. He is homeschooled and gets 75% of his work done. Math is the worst time for OCD, and it can take 2.5 hours.

    I know family devotions or going to church or reading the Bible can trigger scrupulosity (currently his only OCD issue), so what should we do when we can’t continue through his noise level? (He doesn’t want to be excused from family devotions–he wants to participate.) Is it out of line for us to want him to be less vocal when he is suffering? We are a compassionate and loving family and we don’t dismiss his very real suffering. We just wonder if he should have more control over how he shares it? I have read that ADHD children are three years behind in maturity, so maybe his response has to do with his immaturity (comorbid conditions: ADHD, dyslexia, dysgraphia).

    I want to make sure my reminding him of therapy techniques in the middle of an attack is not enabling him. Should a parent educate him, and then step back and let him come to the conclusion on his own that he needs to utilize what he’s learning? Since he has ADHD we wrote down some techniques and posted them on the walls. Is that enough help, other than continuing the search for appropriate therapy, and praying for him, and expressing sympathy? He seems to come to me when he is upset as a rule, but what new things can I say? At some point he has to be able to incorporate them without being reminded. Does this get easier after puberty–does the anxiety threshold lower as the hormones even out, so that he can think clearly about the techniques?

    To recap, my questions are: Does puberty make OCD worse as a rule?; Can we expect him to be less vocal in his suffering?; Is reminding him of techniques several times a day enabling him? I DON’T reassure him that he doesn’t love Satan, or that he’ll never forsake his faith, or anything of that sort. Thank you very much!

    • sethgillihan says:

      Thank you for your excellent questions, Christine. Puberty certainly can be a trigger for increased OCD. That said, it’s not a rule that it has to make OCD worse–even when it’s happened to a sibling. So while it’s good to be aware of times of risk, I wouldn’t necessarily expect that the transition would affect every child in a family in the same way.

      Second, I do think it’s reasonable to ask that a loved one with OCD make certain changes. If the person isn’t able to make the changes, then a family can require that the person get the treatment s/he needs, and more intensive treatment if the current level isn’t enough. As you described, this issue is a delicate one because you don’t want to set up unrealistic expectations on one hand, and don’t want to allow the family to be overly controlled by the OCD on the other. OCD specialists often can work with families to help balance these issues–which, by the way, most families have to navigate when a family member has OCD. (By the way, I would recommend Jon Hershfield’s excellent book by that title, which should be available at the end of this year: http://www.amazon.com/When-Family-Member-Has-Obsessive-Compulsive/dp/1626252467.)

      Finally, reminding of techniques can be helpful or it can be enabling, depending on the person. Often it’s helpful to have a conversation with the individual with OCD to find out how best to help, and whether reminding is effective, annoying, reassurance, etc.

      Hope this helps. I wish the best to you and your family.

  49. Anon says:

    What do you do if you get an intrusive thought during masturbation? Just disregard it and continue thinking about what you want to think about or? Should you stop? Is it weird to just disregard it and carry on masturbating? Is it weird if, like it’s disturbing definitely, but you don’t want it to control your life, so you don’t want to stop, but just disregard it and move on?

    • sethgillihan says:

      Thanks for the question, Anon. Masturbation is like anything else–we don’t want to let our actions be dictated by OCD-related thoughts. So if an intrusive thought occurs while a person is masturbating–or doing anything else–it would very likely only feed the OCD to interrupt the behavior because of the thought. The question would be less about if it’s weird or not, and more about what’s the most effective way to respond to intrusive thoughts. In general the best response would be to carry on with masturbation in spite of the thoughts.

      Now, it’s an important point you raise about “disregarding” the thoughts. It depends on what we mean when we say, “disregard.” Sometimes we mean “force my mind to think about something else,” which tends to be a surefire way to make the mind keep coming back to the intrusive thought or image. A better approach is to acknowledge the thought–“Yep, there you are, I see you, Thought”–and then gently bring the attention back to the activity at hand. The more we struggle to get rid of thoughts, the more importance we give them and the more we feed them. When we just let thoughts be, they tend to dissolve more quickly.

  50. piyush handa says:

    hiii sir iam having very swere ocd from 10 years now….i got many intrusive religious se ual abusive thought because of these i always engage in doing tics,rituals and all…iam married now from 1 month plz tell me how can i do my erp for this illness plz….

    • sethgillihan says:

      Thank you for your question, Piyush. For any intrusive thoughts we work in ERP to face those thoughts–even think them deliberately–without doing any of the rituals and other responses that you mentioned. With repeated practice the obsessions tend to be less frequent and less upsetting, and it gets easier to resist doing the neutralizing behaviors. I wish you the best.

  51. marcel says:

    Hi Seth, I’m almost positive I have ocd but sometimes I doubt it and think there is truth to the thoughts. This leads me to engage in a “figuring it out compulsion” where I either analyze my past thoughts/feelings/actions, try to become enlightened somehow so that I will gain control, or convince myself they aren’t true. The main thing is just thinking deeply all the time about it and to somehow make sense of it all and find some answer so that it will all end.. But this is probably magical thinking and not realistic. It also has lead to constant self monitoring. I haven’t talked to anyone yet because I thought I could overcome it on my own but I’d like to hear what you think. Thanks!

    • Hi, Marcel. It’s a good insight you have when you call the analyzing thoughts a “figuring it out compulsion.” It’s an understandable one, since there’s the hope that it will lead to something freeing in the end. And as you’ve experienced, it doesn’t sound like it leads anywhere, other than to more trying to “figure it out.” As with all OCD, the best course is probably to let the doubt be there and not allow it to control what you do. Best regards for your ongoing recovery!

  52. josh says:

    Dr. Gillihan,
    I have feared masturbation for over three years now. When I started doing it I was 10 but I noticed that I was feeling very much OCD and anxiety after. I fear that if I do it after 2 years, I will revert to an old state of OCD. I fear that I will not be the same person and I will change in some way. I was thinking exposure therapy would help (doing the act of masturbating) but I am too scared. I need a professional to tell me it is okay and I should go on with the exposure therapy.
    Thanks

    • Thank you for your comments and question, Josh. When we’re unsure if something is OK to do, it’s common to want someone to reassure us that it is. If the anxiety and uncertainty remain even after reassurance, it’s almost certainly the OCD and we would need to do the thing we fear despite the anxiety (assuming the thing we’re afraid to do isn’t actually wrong in some way.) With practice we will start to feel more comfortable, and will likely discover that what we’re afraid of doesn’t happen. All the best to you!

  53. Damian West says:

    Fantastic article, thank you.

  54. David z says:

    Very hard work breaking rituals when new ones come at you everyday

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