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OCD
- Obsessive Compulsive Disorder
irrational
compulsions......in plain English.
First
of all let’s recognise that OCD is diagnosed “by
degree of severity”. In other words it’s a label. So
whether you have been formally diagnosed as having OCD
or not; where obsessional and/or compulsive problems
exist then the principles of treatment remain the same.
Here
we borrow from the DSM IV (Diagnostic and Statistical
Manual of Mental Disorders) to outline the criteria for
OCD diagnosis (Please do not use this information to
self-diagnose. It is here for information purposes
only!) : -
To be
diagnosed with Obsessive-Compulsive Disorder, one must
have either obsessions or compulsions alone, or
obsessions and compulsions, according to the DSM-IV-TR
diagnostic criteria. The Quick Reference to the
diagnostic criteria from DSM-IV-TR (2000) describes
these obsessions and compulsions:
Obsessions
are defined by:
1.
Recurrent and persistent thoughts, impulses, or images
that are experienced, at some time during the
disturbance, as intrusive and inappropriate and that
cause marked anxiety or distress.
2.
The thoughts, impulses, or images are not simply excessive
worries about real-life problems.
3.
The person attempts to ignore or suppress such thoughts,
impulses, or images, or to neutralize them with some
other thought or action.
4.
The person recognizes that the obsessional thoughts,
impulses, or images are a product of his or her own
mind.
Compulsions
are defined by:
1.
Repetitive behaviors or mental acts that the person feels
driven to perform in response to an obsession, or
according to rules that must be applied rigidly.
2.
The behaviors or mental acts are aimed at preventing or
reducing distress or preventing some dreaded event or
situation; however, these behaviors or mental acts
either are not connected in a realistic way with what
they are designed to neutralize or prevent or are
clearly excessive.
In
addition to these criteria, at some point during the
course of the disorder, the sufferer must realize that
his/her obsessions or compulsions are unreasonable or
excessive. Moreover, the obsessions or compulsions must
be time consuming (taking up more than one hour per
day), cause distress, or cause impairment in social,
occupational, or school functioning (Quick Reference
from DSM-IV-TR, 2000). OCD often causes feelings similar
to that of depression.
The Science of OCD
So,
what is going on in an OCD sufferers brain? Well,
keeping it as simple as possible:
·
The Orbital
Cortex – This area of the brain is located just behind
the eyebrows. It is involved in the initial perception
of fear and danger. It detects whether something is
“right” or “wrong”.
·
The
Anterior Cingulate Gyrus is activated by detection of
fear and causes our mood (the feeling that something is
not right) to respond with fear sensations such as
churning stomach and anxiety.
·
The Caudate
Nucleus is the “filtering station” for the thoughts
which come from the Orbital Cortex. It is involved with
“automatic transmission”, which means it is the part
of the brain which switches from one thought or
behaviour to another. It is basically the on/off switch.
It
looks complicated but it is worth understanding. It is
believed that in OCD sufferers the Caudate Nucleus
dysfunctions. The Caudate Nucleus is like a gate. It has
an on position and an off position. “On” means
action is required. “Off” means everything is ok. In
a non-OCD person, when a fearful perception (an error
detection) comes in through the Orbital Cortex and is
passed to the Caudate Nucleus for “filtering” it is
usually dealt with appropriately (we act) and then the
Caudate Nucleus having responded, switches from “On
(Action required) to “Off”(action not required) .
Thus the gate closes and the automatic transmission
shifts gears back to “ordinary” awareness. It is
believed that in OCD sufferers (and we note that this
can be due to over-use of the mechanism because of
negative introspection, anxiety, and continued worry),
the gate gets stuck in the “on” position. “On”
becomes the norm. Here we have compulsions….the
feeling that even though we have acted there is still
more to do, because normally this gate would close and
the urge to act would cease. In OCD, it doesn’t close,
so the urge continues. Now we have an extra problem too
because this feeds back to the Orbital Cortex that
something is STILL wrong, and this arouses the Orbital
Cortex further that there are “errors” which it
sends back to the Caudate Nucleus which then tries to
put it right by acting, and round it goes in a vicious
cycle; each part of the brain continually arousing the
other! Put simply then, the filtering mechanism which is
the Caudate Nucleus fails to filter properly and the
feeling that something is wrong persists and increases
with each cycle. The Orbital Cortex literally overheats.
It becomes highly over-active, and this means that it
too starts to dysfunction and detects more and more
errors and so on it goes. Now, if this wasn’t bad
enough already, to add to the mix we have the fact that
now the Anterior Cingulate Gyrus gets involved too. In
OCD the Cingulate Gyrus, which is responsible for the
modulation of “feelings” gets “locked tight” to
the Caudate Nucleus, and this creates feelings of fear
and dread, or at the very least unpleasant “moods”.
The amygdala which is responsible for extreme fear and
panic, can also be triggered into action by these faulty
messages.
The
understanding is then that in treating OCD we have to use the
Frontal Lobes (what we would refer to as the
Intellectual or Executive brain/mind) to do the job that
the Caudate Nucleus is failing to do properly. Studies
have shown that when the Caudate Nucleus is not working
properly then the cortex (the Intellectual
or Executive brain/mind) must help out, so conscious
thought is necessary to shift behaviours.
Shifting thoughts and behaviours is no longer
“automatic” and we now have to use the intellect to
do it. So using the Cortex to stand in for the faulty
Caudate Nucleus, we can get the brain to re-wire. Again
we know that the brain shows a certain amount of
“plasticity” meaning that the brain can re-wire
itself in certain ways. If one part stops functioning
properly, then it can often find another way of creating
the necessary function. The team at UCLA found a link.
They found that there is a pathway from the Basal
Ganglia (The Caudate Nucleus) to the Frontal Cortex
which would explain why the two areas can demonstrate
this plasticity. It is of course the continued
repetition of shifting thinking, and the conscious
re-adjustment of responses and behaviours which creates
the change. Understanding this also complements our own
way of thinking that by reducing anxiety generally we
return more control to the Frontal Cortex (the
Executive/Intellectual) brain. This is true in all
people, not just in OCD. In so doing we make it
literally easier to undertake the behavioural
therapy.
The picture shown here
gives us even more leverage in approaching OCD
rationally. We can see that there are basically two
routes for incoming information. If you look at the
"incoming signal" you will see that the
information incoming (first solid arrow) goes to the
Thalamus. The Thalamus is the brains central relay
station. It is the thalamus which makes the initial
assessment on where to route information. As part of our
primitive survival mechanism we see that there is a
short cut route which goes directly to the amygdala
which is represented here by the red arrow marked
"Short Circuit". The second larger solid black
arrow (signal continues) is also information being
routed to the amygdala but you will note that this
second bunch of information is routed via the visual
cortex (or if it's a different perception such as a
sound then it's routed through the relevant processing
area). This is clearly a longer route, and it
consequently takes more time to register. We can see
that the information routed via the visual (or other)
cortex arrives at the amygdala as a "fuller
assessment signal".
It is interesting that
we can respond to incoming information before we have
become consciously aware of any danger. Consider how an
eyelid will close automatically to protect the eye when
a projectile comes close. You don’t register the
projectile and then close your eye…it happens
automatically. What we are seeing here is the brains
natural mechanism for split-second reactions. There may
be literally milliseconds of difference in reacting and
registering but these milliseconds can make all the
difference in emergency situations. If you think about
your own experiences in this regard, have you ever
experienced something which made you jump before you
knew what it was and then immediately afterwards you
recognise that the threat level was overestimated and
you relax? What is happening there is that the first
bunch of routed information short-circuits the visual
cortex and goes straight to the amygdala, which is the
area of the brain which registers immediate fear and
panic…evasive action! There is an immediate response
or reaction. Literally milliseconds later, the longer
routed but much more complete picture arrives via the
visual cortex (and other “sorting” areas of the
brain”). So the initial short circuited information is
very vague. The brain doesn’t quite have the full
picture of the threat but it responds with fear anyway,
because it is better to be safe than sorry! Here’s
where it gets interesting for us though because the
second bunch of information which carries a much fuller
analysis of the situation can now “dampen” the fear
response if it is considered that the threat is less
urgent than the first impression suggested. This is
natural. Suppose there is an explosion in front of you.
You duck, flinch, screw your face up and close your eyes
tight. Half a second later you see that the cat knocked
your favourite vase off the kitchen windowsill and it
has shattered into a thousand pieces. What do you feel?
Sorry for your vase yes, but more immediately than that
…initially relieved. This is the dampening
effect that the second fuller routing of information
brings. On recognising that the danger is not life
threatening, your system immediately calms itself. All
this in 1-2 seconds!
So why does this
matter to us? Well, think about how OCD works. An
obsessive thought comes in. There is immediate alarm.
What is this? Well, this is information bunch number one
bypassing the intellect and going straight into the
limbic system (the emotional mind of which the amygdala
is a part!). So the immediate initial feeling is one of
“wrongness”. Then information bunch number two
arrives just milliseconds later. Now here is where OCD
does its mischief. Because the “feelings” are so
pervasive with OCD, invariably here, the sufferer
“buys in” to the assumption that something is
terribly wrong, and the “worry” circuit goes on. You
are not to be blamed for that. We know it feels for all
the world as though something is terribly wrong. The
thing is though…..It’s Not True! So this is
really important to understand. You get two shots of
information. The first you can do little about initially
(although hypnotherapy is great for sorting out the
first bunch of signals…I’ll explain that
separately), so you get the feeling, but you must
recognise that the second shot of information IS
up for grabs! You have to recognise a) that you can do
something with this second bunch of information, and b)
that you have to become practiced in the art of catching
it at work before you “buy in”, and then amending
your conscious awareness of what that feeling really
means, thus “dampening” the fear. We don’t expect
it to go away altogether immediately, but the minute you
realise that you CAN make a difference, even if it’s
only a minor one, then you are on your way back to
control! This is an excellent model for helping you to
really understand HOW to overcome OCD. As you begin to
see more and more the truth of this in action you will
become more and more adept at catching the OCD before
it’s had time to worry you. Later in this article you
will find Dr Schwartz’s 4 step plan for making this
process rock solid!
So, for clarity,
let’s now focus on what you need to be remembering:
Patience….Perseverance…..Trust.
Sounds brain-washy doesn’t it? Good! That’s exactly
what we need to wash these faulty perceptions out of
your brain! In order to do that we need your: -
Patience:
It takes time to overcome OCD. Usually months. With
regards to your treatment, that doesn’t mean that you
will necessarily need to have a session every week for
the next however many months. Treatment can be spread
out over longer periods of time once we’re underway.
But it is SO important that your expectation is
realistic. In our modern culture we often want
everything now, and it’s often delivered now,
so we can come to expect that all too easily. Some
things in life don’t work that way. OCD is one of
those things. In
terms of what OCD is, it’s worth remembering that
these patterns of thought and behaviour have been
engrained over a long period of time and it just simply
takes time to change patterns like these. We overcome
OCD by winning small
victories which increase confidence, which change
the way the brain is patterning behaviours and feelings
and then bit by bit…inch by inch we take back control.
It is crucial to get this into perspective from the
beginning of treatment. You might remember Jade Goody
collapsed in her London Marathon attempt in 2006 because
she failed to recognise that you can’t just run a
marathon without any training. In other words she failed
to prepare properly for the task ahead.
The same principle
applies here except that your preparation is Mental
rather than physical and it comes from recognising that this
is a marathon…. not a sprint!
I wish I could tell
you otherwise, but please do not let this fact
dishearten you. You don’t have to have reached the
finish line to be feeling good about the race. As you
make progress it will become easier and easier to build
on that progress. It is ALL forward movement!
Perseverance.
Overcoming OCD
requires perseverance. Some days you win. Some days you
lose, but as long as we win more races than we lose, in
the long run we are winning! Therefore we require
courage and determination. It’s a subtle mix of being
strong yet compassionate with ourselves. Pushy yet
sensitive. We need to dig deep and hold that
determination…remember these words ….“never give
up …never give up!”. In practice it’s usually the
case that we take three steps forwards and one step
back. Expect this and you will then be mentally prepared
for setbacks. Then you can say “Ok….I knew this
might happen, but it’s temporary…I made good ground
before …I will do it again…this is a difficult
time…it will pass”. Use your heart (emotionally
speaking) to fight for your life. Be clear about your
intent. Be clear that you will do what it takes to
overcome this difficulty. There is so much power in this
stance. Resolve to stop being a victim and dig deep to
find the determination to beat this thing. We know it
CAN be done, so be determined that you’re going to be
one of the winners! And if you fall off, then get up,
dust yourself off, and get back on! Remember that courage is not the absence of fear -
it is the decision that something else is more
important than that fear….in this case your life! True
courage is based on being willing to support oneself
emotionally even when the fear is telling us it’s
impossible. A lovely old Confuscious quote comes to
mind. “He who says it cannot be done should not
interrupt the person doing it!” He who says it cannot
be done in this case is your OCD!
It is unfortunately
true that healing often takes place at a cost to the
person being healed, but do remember that the cost is
temporary but the resulting good health is priceless.
You are not a bystander in this therapeutic process.
Quite the opposite in fact. This is an “active”
process, meaning that work done takes place in every day
life as well as during our therapeutic sessions. The
price in this case means making changes. It means
effort. We have to be willing to pay that price. It
means being willing to challenge old patterns, to think
new thoughts, to try new behaviours. This takes energy.
There is expenditure. It’s all change, and that often
feels scary and costly to an unconscious mind. We are
entering the Unknown as far as the unconscious mind is
concerned (Who are you if you are not your OCD?) It’s
a well established fact that the unconscious mind left
to its own preference will often opt for the miserable
but familiar over the functional but new/novel. Why?
Because familiar is seen as safe even if it is
miserable! (Better the devil you know) Knowing that your
mind is likely to want to keep you in old patterns even
though you want rid of your OCD is an important fact to
recognise because now you are becoming clear that you
won’t let the OCD manipulate you any more! Some days,
many other factors may contribute to you not feeling
strong enough to deal successfully with the OCD. If that
happens….it’s okay! Be kind to yourself, and remind
yourself that tomorrow you live to fight another day!
This is why it’s so important to dig deep and to
cultivate perseverance.
Here are some courage
quotes to get you inspired!
True
courage is not the brutal force of vulgar heroes, but
the firm resolve of virtue and reason. ~Alfred
North Whitehead
Courage
is the power to let go of the familiar. ~Raymond
Lindquist
Courage
doesn't always roar. Sometimes courage is the
little voice at the end of the day that says I'll try
again tomorrow. ~Mary Anne Radmacher
People
are made of flesh and blood and a miracle fibre called
courage. ~Mignon McLaughlin, The Neurotic's
Notebook, 1960
It takes a lot of courage
to release the familiar and seemingly secure, to embrace
the new. But there is no real security in what is no
longer meaningful. There is more security in the
adventurous and exciting, for in movement there is life,
and in change there is power.
"When
you are forced to bear the unbearable something dies in
you.
What dies in you is whom you thought you were that
couldn't bear the unbearable." "Bearing the
unbearable is the root of the deepest compassion."
Ram Dass
Patience
and perseverance have a magical effect before which
difficulties disappear and obstacles vanish.
When a resolute young
fellow steps up to the great bully, the world, and takes
him boldly by the beard, he is often surprised to find
it comes off in his hand.
Trust
There will be tough
days. There will be easy days. There will be days when
you know for sure that there are improvements and there
will be days when you’ll convince yourself (despite
the evidence to the contrary) that nothing has changed.
Here is where Trust is a great strength. Let’s be
clear that whether we have OCD or not we all have days
where we feel like throwing the towel in. We have to
cultivate Trust in life. It’s my personal belief and
it’s only a belief (but one which has been shown to be
true in my experience), that when we really commit to
healing (Being clear we’re doing it….. whatever the
cost!) then “providence” moves for us. That is to
say life begins to reflect back to us what we need in
order for that to happen. We could speculate on this
phenomenon but it’s a well noted (and scientifically
verified) fact that people who believe they are lucky,
are in fact luckier (they win more and succeed more),
than those who believe that they are not lucky. In other
words, once you believe that it’s possible for you to
overcome your OCD you then actually set in motion the
processes which lead to that positive reality occurring.
So this in fact is Trust. Trust that if you do your bit,
then providing you’re willing to follow the steps of
patience and perseverance, that eventually you will get
the result you are working for! We know in fact that Dr
Schwartz’s four step behavioural therapy; That is
Re-label, Re attribute, Re-focus and Re-value has been
shown to consistently improve OCD sufferers lives. Using
brain scans, Dr Schwartz and his team were able to show
conclusively that the area of the brain implicated in
OCD was far less active after successful behavioural
therapy. This effectively PROVED that this style of
therapy was literally changing the way an OCD
sufferer’s brain was working. Therefore, if you have a
day where your OCD is telling you the whole thing is
pointless and useless (and it feels that way too),
it’s important to TRUST the process and trust the
therapy. The evidence is there. OCD can be overcome, and
as far as we know, this therapy is the most effective
way of doing that. We know it works. We know that anyone
can use it. Trust that by following the steps of the
formula and by continuing to demonstrate patience and
perseverance in the face of adversity that things ARE
improving and WILL continue to improve!
So
what do you need to do?
Okay, Well, let’s
break it down.
Firstly, we need to
reduce anxiety generally. Why? Well, OCD is an Anxiety
Disorder. The formula is: Negativity creates anxiety,
anxiety is converted to fear and fear must have a focus.
The focus then is your obsessional worry. So OCD is
NEVER just about your obsession or compulsion. It
is ALWAYS about anxiety. You can help by by reducing your negativity
generally as well as making a commitment to relax more.
Here though we also find the first step of the four step
behavioural therapy:
Re-label:
This feeling that something is wrong is due to my
general anxiety but my brain is mis-firing as a result
of that anxiety and the fear is being focused on this
obsessional thought. Thus the focus of my obsession is
NOT real, it is only a feeling that my brain is
mistakenly generating which is due to anxiety. Here you
have re-labelled the obsession (the focus of the fear)
and by doing so have taken the first step in resuming
control because you are not “buying in” to the lie.
The main characteristic here is that the feeling IS NOT
YOU! You are not a bad person because you had the
thought. The OCD is not who you are. Be clear about this
by re-labelling and seeing the OCD for what it is….. a
misfiring signal…a false alarm!
Secondly, we need to
recognise where and why this feeling is present. Here we
have step two:
Re-attribute: We know
that the cause of the feeling that something is wrong is
in the fact that the emotional centre of the brain, the
housekeeping function, has become mistakenly concerned
that we are being threatened. We can therefore KNOW
intellectually that the feeling we are having is the OCD
and not the problem which it FEELS like. Therefore we
are learning to distinguish between what is objectively
REAL and what is an overdone emotional response. when
you ask yourself “Is this a reasonable response?” If
you can’t honestly answer that rationally it is
reasonable, then you know the feeling is deceiving you,
and it’s not
a real fear ..it’s OCD. The rule to remember is that
OCD can mimic reality but reality can never mimic OCD.
In other words the rule for this is “If it feels like
it might be
OCD then it is OCD!” You recognise “I am not
the thought. I am not the feeling. I am the
observer”. Then you can now say “This is not
me…it’s the OCD”. So now you have relabelled the
feeling as “not you” and re-attributed it’s
importance by recognising that the feeling is
attributable to a faulty Caudate Nucleus and anxiety
generally (the OCD) and not the object of obsession.
Re-Focus:
Go and DO
something else. It is very important that you recognise
the importance to DO something differently. This is the
crux of the therapy. It is not enough to simply think
about doing something differently, one must actually DO
something differently. So suppose the compulsion was to
clean ones hands, well here you will actually change
course and decide to do something else. Using the first
two steps as your mantra you continually remind yourself
that the compulsion to clean your hands is not truly
proportionate to the perceived danger (it is a misfiring
in the brain!) and you go and DO another activity. This
has the practical effect of changing the habit of doing
what you have always done, disagreeing with the
unconscious minds assertion that you must be in danger.
By refusing to carry out the compulsion you send a
message back to your unconscious mind that says “I
disagree with the feeling you are sending and I refuse
to act upon it. You will need to make the adjustment.
Not me!” It is this process which over time causes the
brain and the mind to begin to literally function
differently. The brain adjusts. The unconscious mind
works on a feedback loop and as we discover through
repetition that nothing untoward occurs when we refuse
to carry out a compulsion then the brain eventually
starts to take this on board and change the assumption
(and the feeling) that something is wrong. You can see
therefore that the opposite is also true that when you
carry out a compulsion you actually strengthen the OCD
because you are saying to the brain “Yes, I agree that
there is danger and I will take steps to fix it” So
here then DOING something differently changes the
message. It is
this process which over time causes the brain and the
mind to begin to literally function differently.
Practically speaking you need to have some alternative
behaviours to hand that you can switch into to occupy
your mind. The behaviours should be pleasant and
constructive. Ideal behaviours are something you can
really distract yourself with. So arts and crafts are
obviously good. Learning a language might help (but not
if it’s stressful for you), but practically any
hobby-like activity will help, as long as it is
something where you can literally re-focus your mind.
See if you can commit to the 15 minute rule. If you can
last fifteen minutes reminding yourself that the
feelings and thoughts are faulty messages from the
brain, then you will often find that the feelings fade
before the 15 minutes are up! Each time you do this, you
are winning! If you really can’t do 15 minutes, then
pick the longest time you think you can do, and
challenge yourself to do longer each time. Build it up
as you go. Make
a note of ANY positive change. This leads to the
pay off in the next step.
Finally we have:
Re-value:
So this is the pay-off
step. Re valuing is where you get to see for yourself
that obsessional thoughts and behaviours (compulsions)
are truly “worthless distractions to be ignored”. In
practice this is what overcoming OCD is all about. So as
you look back on each victory and see that by re-labelling,
re-attributing and re-focusing you were able to beat the
OCD, so you also can then re-value the
obsession/compulsion with the benefit of this
information. Every small victory you have with
overcoming an obsessional or compulsive pattern is one
step nearer to being OCD free because each time you win,
you revalue again. Over time this gets easier and easier
as your brain begins to really cognise that the fear
(obsession and compulsion) is really unnecessary. The
general principle here is that seeing (your results) is
believing, and that the more clearly you see what OCD
symptoms really are, the more rapidly you can dismiss
them as worthless garbage that is not worth paying
attention to.
Conclusion.
We have chosen
to use the Dr Schwartz 4 step plan outlined here because
to the best of our knowledge this plan has been shown to
be the most effective treatment available for OCD with an 80% success rate
with no relapses that come close to pre-treatment
severity. It also sits beautifully within the principles
of hypnotherapy which follow very similar understanding.
The two treatments therefore work very well together,
and the process of using hypnotherapy together with this
behavioural treatment proves to be highly effective.
If you would like to
learn more about Dr Schwartz’s methods and research
you can buy the book “Brain Lock” from Amazon or
most good bookshops. There are a number of OCD help
resources available online. A nice new resource site on
OCD symptoms and resolutions can be found at http://www.ocdsymptoms.co.uk
There is more
information available on OCD on my sister website here. You can contact me to
make an appointment here. |
