🔼: [[Medical Conditions and Diagnoses]] ##### Obsessive-Compulsive Disorder > [!note] > This note remains a work in progress as I explore my own OCD spikes as they arise. My hope is that the map I’ve drawn here is complete enough to be of value to others (as it already has been with folks I know personally). If you find this useful or not, or if you’ve found other resources or ways of seeing OCD that have helped you, feel free to [[📬 Contact|📬 Contact me]] and share. I am by no means an OCD expert — be sure to check the list of resources near the bottom of this page for more. A term referring to what is fundamentally an inability to tolerate the [[💡 Anxiety|anxiety]] that arises in response to uncertainty about [[#OCD Themes|very specific things]]. OCD demands absolute certainty that something isn’t true or isn’t going to happen. The trouble is, it will never be satisfied by any answer, by any amount of evidence — this is why it’s known as “The Doubting Disorder.” OCD demands water-tight evidence and then puts a microscope on that evidence and highlights even the smallest of uncertainties, and then demands more evidence to rectify them, but that evidence too has uncertainties in it. The World Health Organization classifies OCD as one of the top 10 most debilitating conditions in the world. When OCD isn’t attended to, it is a hellish, tortured way to be in the world — it can diminish a person’s life to enormous suffering and isolation which can extend to the people who love and want to help them. It’s also *very* treatable. ###### Understanding OCD OCD begins with [[Intrusive Thoughts|Intrusive Thoughts]] — unexpected, unwanted inner-talk or inner-images that run counter to our [[⭐ Values]] and latch onto what we’re afraid of. Intrusive thoughts are normal and natural, the overwhelming majority of people get them and are able to dismiss them as odd or mildly amusing and then go about their day. If we’re experiencing what we call OCD, there’s a [[💡 Parts|part of us]] who notices, focuses on, and picks at that thought with a kind of frightful curiosity which very quickly turns into [[🛡️ Ruminating|🛡️ Rumination]]: “What does this mean? Why am I thinking about this? Is this something I want? If I don’t want to do this, why am I thinking about it?” If the [[Intrusive Thoughts|Intrusive Thought]] was something said to us by another person it might be easy shrug it off, but because it arose out of our own mind it’s much more difficult to dismiss. Because *if it isn’t true, why am I having this thought? Is this not exactly the kind of thought I would have if it were true? What does this mean about me?* As this continues, the [[Intrusive Thoughts|Intrusive Thought]] (which perhaps began as a whisper) gets bigger and bigger until it takes up so much space in our mind that it’s the only thing we can think about. It’s like a watchful part has spotted something they don’t like and can’t make sense of, and so they sound the alarm and force every available spotlight to focus on it so that it’s the only thing we can see. At this point the [[Intrusive Thoughts|Intrusive Thought]] and [[🛡️ Ruminating]] becomes an [[💡 Obsessions|Obsession]]. The watcher has fixated onto it and is too worried or too terrified to let it go, because the thought feels like a threat to our [[⭐ Values]] or identity. The watcher is convinced that the thought is *really* important and needs to be figured out **right now** because they’re afraid that it might be true and that would be *very, very bad*. Soon after, a [[💡 Reactive Protectors|Reactive Protector]] arises to soothe the [[💡 Anxiety|anxiety]] through what we call a [[💡 Compulsions|Compulsion]] — something we either do or think in order to feel certain that the [[Intrusive Thoughts|Intrusive Thought]] is either definitely not true or definitely won’t happen and lets us stop trying to figure it out. This can look [[💡 Compulsions#Examples of Compulsions|several different ways]], but one example: asking for reassurance. We might say to our loved ones, “Hey, I did something messed up and it hurt someone and I feel really terrible about it and I’m scared that I’m bad (the [[💡 Obsessions|Obsession]]). Am I bad? Do you all think I’m a good person? (the [[💡 Compulsions|Compulsion]])” The people who love us will likely tell us something like, “No, of course you aren’t bad, you’re just a person and you made a mistake and it’s okay, you’re wonderful,” which makes the [[💡 Anxiety|anxiety]] subside. But with OCD the anxiety isn't the problem – the problem is the striving for certainty. > [!NOTE] > Having an [[💡 Obsessions|obsession]] or [[💡 Compulsions|compulsion]] doesn't mean we have OCD. For OCD to be available as a diagnoses we have to experience some kind of rupture in our quality of life or basic functioning and have lost time trying to manage it. Though some of us might not recognize just how much time we've spent trying to manage it if we've been living with it for years – we might be blind to it. If we experience OCD, this reassurance might help that [[💡 Parts|part of us]] feel better for a time (minutes, hours, days), but it won’t be enough because *nothing is certain*. That part of us who is so afraid of that thought and is desperately demanding certainty cannot ever be satisfied by evidence. In this case that part of us might arise again and say, “But what if they weren’t telling the truth, what if they’re actually judging us but didn’t want to be honest? I didn’t tell them this detail about it, so they don’t actually have the full story. Maybe they just don’t fully understand how badly I messed up,” and the [[💡 Anxiety|anxiety]] arises again. This starts the [[💡 Vicious Cycle|Vicious Cycle]] of OCD. In order for that part of us to feel the (false) sense of certainty again, it escalates its need for absolute proof that the thoughts aren’t true or won’t actually happen: “Okay, I know we’ve talked about this before, but do you actually think I’m a good person, or were you just trying to make me feel better? Do you promise? Look at me in the eye and tell me. Do you swear to God?” And that might help, for a time. But *nothing is certain*. The watcher will always seek out cracks and vulnerabilities in the proof that our [[💡 Compulsions|Compulsions]] give us, they will **always** find it and then sound the alarm again, because those cracks are opportunities for the [[💡 Obsessions|Obsessions]] to be true and this part of us *desperately* wants to keep us and others safe and to live in alignment with our [[⭐ Values]], to be a safe, loving, and good person. So the cycle repeats again and again, escalating each time as this watcher continues to attempt the impossible. This loop starts to wrap around our life, getting tighter and tighter as these [[💡 Compulsions|Compulsions]], which a part of us is absolutely convinced will make the [[💡 Anxiety|anxiety]] feel better (because the compulsions gave temporary relief in the past) actually makes us feel worse and worse as our life gets smaller and smaller because more and more time and energy is spent trying to find certainty *which cannot ever be found*. This cycle is how a person can start with a concern about having germs on their hands that might make them sick after touching the floor ([[Intrusive Thoughts|Intrusive Thought]]) to spending enormous amounts of time and energy keeping their floors clean and washing their hands to the point that they’re dry, cracked, and damaged ([[💡 Compulsions|Compulsions]]). ###### Why does this happen? OCD is likely a [[Symptoms of Unresolved Trauma|symptom of unresolved trauma]][^1]. It isn’t clear whether early [[💡 Trauma|Trauma]] leads to neurodivergence, whether people are born neurodivergent and just have much higher chance of experiencing trauma in a neurotypical world, whether the parents or grandparents experienced trauma which changed their genes and manifests in their descendants as neurodivergence, or some combination, or something else. ###### Tending to OCD *Certainty is not possible*, which means [[💡 Compulsions|Compulsions]] are not the answer. We might consider our OCD, in whatever form it takes, not as an evil or a prison or a anything like that, but as *a puzzle*, or as a game. We might imagine ourself as a level 1 character or solving the level 1 puzzle. Each puzzle, each level, is meant to be challenging for where we are, what we know, what skills we have *right now*. What’s the first level? Sometimes when we're exhausted, depleted, [[💡 Burnout|burned-out]], petrified, disabled by our anxieties, we're skipping levels and trying to solve life-puzzles before their time, and [[🔑 the right thing, at the wrong time, is the wrong thing]]. Sometimes we're trying to solve puzzles that aren't puzzles – they're time-devouring traps disguised as puzzles. The way to solve them is to not solve them, because they can't be solved. The trick is to recognize those traps and discern them from real puzzles. If OCD is part of our life experience, we would be wise not forget that. We have a puzzle-brain. Life will continue to give us puzzles and it will de-level us with time if we’re not paying attention, so solve them when you see them. You’ll know you’re seeing a life-puzzle when you feel [[💡 Fear|fear]] or [[💡 Anxiety|anxiety]] — solve it. But we might forget about OCD, and that’s okay. The tutorial to this game isn’t going anywhere. We can re-learn the rules whenever we need to: - If we feel the need to respond to a thought immediately, if we experience a sudden WOOSH of anxiety and discomfort that we want to relieve immediately, it’s almost certainly related to OCD. - Fundamental to OCD is a crippling inability to tolerate feelings of anxiety in response to uncertainty. That intolerance motivates our [[💡 Compulsions|Compulsions]]. We avoid triggering situations or desperately want certain, concrete answers which often can’t be had, and no amount of reassurance is enough. The [[💡 Parts|parts of us]] involved in an OCD constellation demand certainty but won’t accept it. This starts a [[💡 Vicious Cycle|Vicious Cycle]] which makes our life smaller and smaller, increasingly stifling and tightly wound in order to have more and more certainty and control. - [[🔑 Avoidance feels much worse than confrontation]] - For someone with OCD, the goal is not to never ask for reassurance or figure anything out, but rather to become mindful of when these behaviors are driven by OCD compulsions rather than genuine needs. In neurotypical people, seeking reassurance or solving problems is more balanced, whereas in OCD, these behaviors can become excessive and fuel the real problem. Treatment, especially with [[🛠 Exposure and Response Prevention (ERP)]], helps us tolerate uncertainty and reduce [[💡 Compulsions|compulsions]], so that they no longer dominate our lives. It’s about moderating these actions, not eliminating them entirely. Asking for reassurance is okay. If we end up having to ask for reassurance over and over again to avoid distress, and if no amount of reassurance is enough, then we’re likely doing a [[💡 Compulsions|compulsion]]. - For someone with OCD, emotions and thoughts can feel entangled in obsessive cycles, making it hard to trust one’s [[⭐️ Inner-Compass]]. However, [[💡 Acceptance and Commitment Therapy|Acceptance and Commitment Therapy]] and [[🕯️ Mindfulness]] can be helpful approaches. They teach that emotions and thoughts don’t always need to be followed or acted upon. Instead of trying to fix or control them, it’s about noticing and accepting them without judgment. With practice, it becomes possible to differentiate between an OCD-driven thought or feeling and a deeper, value-driven sense of self. This allows for a more grounded way to navigate the world while respecting emotional experiences without getting swept into spirals. - [[🔑 Don’t believe everything you think]] - [[🛡️ Addiction or Dependence]] can be linked to OCD. It's another [[💡 Protector Parts|Protector Part]] trying to keep the emotions down. - [[💡 Depression|Depression]] can sometimes arise because OCD hasn’t been attended to and we’re feeling hopeless about it or convinced we’re awful or dangerous. Sometimes the depression is unrelated, so if OCD does get attended to we start to notice the depression more or it just remains. That just means there’s some other [[💡 Part Constellation|Part Constellation]] to turn our attention toward. - I sometimes think OCD stems from fears of how complicated the world is and how free we really are. - [[☀️ Equanimity]] and [[🕯️ Unblending]]. - [[💡 Limerence|Limerance]] can be OCD %% Two things get reinforced when we give into compulsions. 1. By acting on the thought, we validate and legitimize it. Look at all the work you’re doing, this must be a valid concern. So the thought returns over and over. 2. By refusing to tolerate the anxiety, we reinforce our inability to cope with it. We reinforce that we can’t handle it. The bigger and more consuming it becomes which makes it harder to tolerate. To deal with it: 1. You can’t control thoughts. They can lessen, quiet, be in the background, but can’t be controlled or stopped. 2. You can’t control the feelings that respond to the thoughts. 3. You can control the reaction, and that’s enough. When you can let go of the need for certainty, it dies down. As a therapist who specializes in OCD (and other severe anxiety disorders) and has lived experiences, please refer out to a specialist until you get training or specific consultation by a specialist. Neuroscience and psychological research has learned that OCD does not respond well to general treatment like talk therapy, thought stopping CBT techniques, and other modalities might use assurances. AKA, most of the things were taught in grad school and residency. The part of the brain that is affected by this disorder can be said to be a lot like how trauma has "changed the brain". We would refer other severe disorders to a specialist or risk damaging or wasting their time, we should also do the same for this group of people. Y-BOCS is a great place to start to basically assess if it's OCD. Then you can do more specific assessments or information gathering. It doesn't matter the "theme", as all OCD treatment is treating the underlying issue and not the compulsive symptomology. OCD is marked by compulsions, which can be physical (able to be seen) or mental (all done in their heads). People who struggle with OCD don't feel better or have their worries resolved by facts, logic, statistics, or assurances from others. The trust they have in themselves and reality is skewed by the fear of uncertainty, and their over-active amygdala sending fear signals through their nervous systems. It takes a LOT of work from the therapist help the client notice the cycles and not give assurances, and a lot of work from the client in between sessions to practice their preferred way of life during planned ERP as well as when they are triggered. There needs to be a lot of "whys" for the client because it's a grueling, horrible feeling to go against your brain and the real panic signals. If you are interested in treating this client, or others, with OCD, then good places to start are trainings on ACT specifically for anxiety disorders/OCD (Praxis has a good training), ERP trainings, and these behaviorally-flavored modalities. I like ACT with ERP as it focuses on values, willingness to feel the discomfort to get to your values, acceptance, and mindfulness and weaves nicely into other modalities I jive with. IOCDF.org is a haven of information and trainings and they offer consultation groups, as well. Unpopular caveat: Of course, every client is different and might respond well to different modalities. I don't believe we ONLY have to use a behavioral approach 100% of the time, and wouldn't consider myself a behavioral therapist, but you must know the language of OCD and know when you are at risk of harming a client by perpetuating their cycle of rituals. I wouldn't branch out into other experiential practices UNTIL you learn the behavioral approach, and then get consultation/supervision with someone who is a leader in the behavioral OCD field. DM me if you're interested in some resources. Edit: OP, I'll paste some specific resources and links here when I can. YouTubers, podcasts, etc. %% ###### OCD Themes %% - Could OCD be a sign that we’re over-valuing something? %% Life is fundamentally uncertain. There’s no guarantee that we aren’t going to get hurt when we leave our homes, but most of us go out anyway — we accept the uncertainty. In the same way that [[💡 Trauma|Trauma]] expresses itself in the form of various [[Symptoms of Unresolved Trauma]], OCD expresses itself through various “themes” which represent specific areas of our lives in which uncertainty is intolerable, and it can shape-shift out of one theme and into another or multiple themes at once. These themes very often reflect our [[⭐ Values]]. OCD often fixates on what we most care about, what we most value and cherish what we’re most afraid of. [[🔑 Parts can use our minds and bodies to get or distract our attention]]. - [[Relationship OCD]] - Moral OCD - Pedophile OCD (aka “POCD”) - Harm OCD - [[Scrupulosity OCD]] (Wanting to be a good person; get it right) - false memories OCD - Real Event OCD - Cancel Culture OCD; a fear of being outed and ruthlessly condemned, of not being given grace for our mistakes - Magical Thinking OCD - Fear of certain numbers - Thanatophobia OCD treatment is fundamentally about learning to tolerate the same uncertainty we tolerate in every other aspect of our lives. - [[🔑 Thoughts often come from Parts|🔑 You are not your thoughts]] - Thinking something doesn’t mean it’s true - Thoughts are not as bad as actions; thinking something is not as bad as feeling something. ###### Common Signs and Related Issues - [[🛡️ People-Pleasing]] - [[🛡️ Avoiding]], Risk aversion - [[🛡️ Procrastinating]] - [[🛡️ Perfectionism]] - [[💡 Depression|Depression]] ###### OCD and Parts Through a [[💡 Parts|Parts]] lens, OCD can be seen as a [[💡 Part Constellation|Part Constellation]]. - An [[💡 Obsessions|Obsession]] or disturbing thought (possibly sent by a [[💡 Proactive Protectors|Proactive Protector]]) which goes against our [[⭐ Values]] arises. - Another part of us (possibly an [[💡 Exiles|Exile]]) reacts with immense [[💡 Anxiety|Anxiety]]. - A third part of us, a [[💡 Reactive Protectors|Reactive Protector]], leans into a [[💡 Compulsions|Compulsion]] to try to soothe the anxiety. - They're trying *really* hard to help, though it brings about unintended negative consequences. Anecdotally, I have been told that OCD is sometimes connected to an [[💡 Unattached Burdens|Unattached Burden]]. OCD inspires enormous amounts of [[💡 Fear|fear]] and [[💡 Anxiety|Anxiety]]. Counterintuitively, one of the keys to helping the parts involved in an OCD constellation is to not fear it. ###### Treatments and Supports Parts work can absolutely help with OCD, though it can take time. In the meantime it can be supportive to have cognitive tools. - [[🛠 Exposure and Response Prevention (ERP)]] - [[Metacognitive Therapy]] - [[⭐️ Internal Family Systems]] - [[Mindlfuless-Based Stress Reduction]] - [[💡 Acceptance and Commitment Therapy]] - [[💡 Cognitive Behavioral Therapy]] - [[🕯️ Movement Practices 👟]] - [David Burns’ “Hidden Emotion Model” of anxiety](https://www.reddit.com/r/OCD/comments/tt1lk2/relatively_unknown_fascinating_treatment_model/) - [[🕯️ Dropping Hot Coals|🕯️ Drop the Rope]] - Accept, come to terms with the thought. Accept it as part of your OCD. - Postpone the obsession. Come back to it in the future when you’re regulated. - Write it down, sing it, change the image (exaggerate it, make it ridiculous), write it down. - Write it down, record yourself saying it, let it repeat for as long as you can, up to 45 minutes a day. - Write down the worst fear to get to the underlying fear of the thought. Find out what the thinking relates to, and you’ll often find relief. %% ###### OCD and [[🛡️ Eating Disorders]] - Someone diagnosed with an eating disorder is more likely to be diagnosed with OCD, and vice versa. They're often comorbid and present similarly. %% ![[Nutrition for OCD]] ![[Supplements for OCD]] ###### Resources - [AnxietyOCDDiscernment](https://www.youtube.com/c/AnxietyOCDDiscernment) - [Nathan Peterson | OCD and Anxiety](https://www.youtube.com/@ocdandanxiety) - https://www.treatmyocd.com - https://iocdf.org - Tips for Accepting Uncertainty: https://www.treatmyocd.com/blog/5-strategies-for-accepting-uncertainty - Drop the rope. I don’t know and don’t need to know. It doesn’t need a response. - Accept, come to terms with the thought. Accept it as part of your OCD. - Postpone the obsession. Come back to it in the future when you’re regulated. - Write it down, sing it, change the image, write it down. - Write it down, record yourself saying it, let it repeat for as long as you can, up to 45 minutes a day. - [Psych Hub - 5 Top Tips for OCD](https://www.youtube.com/watch?v=gbXkHPrfh6g) - Would I rather live my life with risk, or would I rather live my life like this? - Am I approaching or avoiding? (the anxiety) - If you can make room for this, for something scary, it will take up less space. - Make it worse to make it better (with a therapist). If you can exaggerate the thought, take it far, to the core fear. This can get rid of the distress. - Stay with the thought, play with the thought. Agree with it ![[💡 Reactive Protectors#Working with Reactive Protectors|Reactive Protector]] [^1]: [OCD is Actually PTSD in Many Cases - OCD Treatment at Gateway Counseling Center](https://www.youtube.com/watch?v=GP83-eeZI2o)