For a very long time, Alex didn’t think of it as a problem, but now, looking back, he realises the signs have been there for a while.

Alex could urinate at home without any effort. At work, he would usually wait until the bathroom was empty. If there was another person there, it took Alex slightly longer to initiate peeing as he felt a bit self-conscious, but he didn’t think much of it.

One day, Alex went to a crowded restroom at a restaurant over his lunch break. There were people waiting to use the urinals.  Alex suddenly felt rushed, watched, and under pressure. He tried to pee quickly, but was unable to produce any stream. He left the restroom feeling humiliated and sensing what seemed like mocking and disapproving stares.

After that, he started paying attention, doing whatever he could to avoid being in this position again.

He began timing when he drank water, which gradually led to more and more restrictions of his fluid intake. Choosing certain bathrooms over others. Peeing “just in case” whenever he had access to a “safe” restroom. Switching from urinals to stalls because they felt safer. He also discovered that it was easier to pee when sitting on a toilet than when standing while using a urinal. But still, if someone walked in, his body locked up. Alex tried to relax and to wait, but the more he tried, the more difficult it was to produce the stream. He would sometimes leave the bathroom, walk around for a few minutes, and come back to try again. Over time, he became worried that others might notice this pattern, and stopped coming back altogether. This led to even more pressure to urinate on the first attempt and even greater difficulty producing a stream.

Over time, the problem spread. Bathrooms that used to be fine stopped working. Even stalls felt impossible if there was any chance that someone could be waiting. Airports, planes, and road trips became a nightmare and he would decline travel whenever possible. Alex consumed less and less fluid during the day, stopped drinking any caffeinated beverages, and avoided situations where bathrooms felt unpredictable. He held urine for increasingly prolonged periods, ignoring physical discomfort.  

Now the anxiety started long before he even entered the restroom. Even the thought of a public bathroom became a trigger, often hours before he would actually need to go. He made sure to mentally map “safe bathrooms” in advance to be prepared and would detour significantly out of his way just to reach one. He sometimes used a single-occupancy, lockable bathroom in a hotel 20 minutes walking distance from his work (which was still tricky as somebody could potentially be lining up outside the door and Alex had no way of knowing that).

The bathroom in Maya’s university apartment that she shared with her roommates was just outside the living room. Maya, a first-year university student, had no difficulty using it to pee when she was alone in the apartment or when her roommates were watching a movie. The problems started when it was quiet in the apartment and her roommates were nearby. Maya would try to use the bathroom to pee but felt pressured, as she felt her roommates might be wondering why it was taking her so long. The more pressured she felt, the more difficult it was to produce the stream.

This became even more challenging in the mornings, as Maya knew that her roommates would be waiting to use the bathroom. She peed while taking the shower with no problem. But on the mornings when she didn’t have time to shower, she would still have the water running, and it really helped.

Public restrooms at university were harder. She couldn’t have water run there, and she could not handle the lines and the thin walls between the stalls.

Maya started adjusting. She avoided drinking any fluids before going to school and stopped carrying her water bottle. Peed “just in case,” when she had an opportunity, even when she didn’t really need to. She learned she could sometimes force it by straining or squeezing, even though it felt uncomfortable. She learned which positions were more likely to lead to successful urination and became over-reliant on positions and breathing patterns. When it worked, she told herself she’d found a solution, but then, when it didn’t, she felt defeated.

When she heard people lining up outside talking, she wondered if they were discussing her. When there was silence outside, she interpreted it as scrutiny.

To escape after fruitless attempts to urinate, Maya would wait for a hand dryer to activate or some other external noise, flush the toilet, and exit pretending to be on her phone to avoid other women’s gazes. She wondered if people waiting in line knew that something was wrong with her and were secretly judging her. She often noticed the girls in the line giving each other a look and a smile, and she was sure they knew. Shame and humiliation stayed with her for a long time. Sometimes the feeling lingered for hours or even the rest of the day.

Maya was also dreading the next uni class, knowing that her bladder was full. This made her fluid restriction even more severe.

Maya left events early. Avoided trips. She panicked before long drives and began structuring outings around where and when she might be able to pee. She said no to things she actually wanted to do. Bathrooms stopped being neutral places and became obstacles she had to manage. Sometimes alcohol helped her pee, but other times it made things worse.

Maya started wondering if something was physically wrong. She finally went to see a doctor, but her UTI test came back negative, and the doctor told her to just relax.

What is Paruresis (Shy Bladder Syndrome)

Paruresis (shy bladder syndrome) is a form of social anxiety characterized by difficulty urinating when other people are nearby or could be nearby. A person with paruresis can urinate without any difficulty when alone at home, but may struggle in public restrooms and in situations where somebody could hear, see, or be waiting.

Paruresis can look different from person to person. For some, it shows up as a delay or hesitation before the stream starts. For others, it can feel like a complete shutdown. Some people struggle only in certain places, while others find the difficulty spreads over time to more and more situations.

A common misunderstanding is that paruresis is a fear of urinating in front of others. But in reality, the core fear is usually about not being able to urinate when others are nearby.

Main triggers of paruresis include public restrooms where other people may be present, feeling rushed, anxiety about being unable to produce a stream or producing a very weak stream, and worry about being judged for how long it takes. Factors such as silence, thin walls between stalls, or a lineup outside the washroom may further increase anxiety.

Paruresis usually worsens with time. In an effort to cope, people start adjusting what they drink, where they go, and how they use the bathroom. These strategies can reduce anxiety in the moment, but over time they reinforce the problem and allow it to spread to more and more situations.

How to Rule Out a Medical Cause of Paruresis

There are some tests that may be indicated to rule out medical conditions such as a urinary tract infection (UTI), cystitis, or an enlarged prostate.

But, if you have no difficulty urinating when you are alone at home, while struggling when other people may be nearby, it’s probably paruresis.

Common safety and avoidance behaviours of people with paruresis include:

·       Restricting fluid intake (which makes urination even harder)

·       Urinating “just in case” whenever a familiar or “safe” bathroom is available

·       Trying to identify and use only “safer” bathrooms

·       Avoiding urinals and relying only on stalls, or only specific stalls

·       Avoiding travel, long meetings, events, or social plans

·       Leaving events early

·       Declining invitations that involve travel, lines, or time pressure

·       Planning routes and days around available bathrooms rather than activities

·       Running water, flushing early, or waiting for hand dryers to create cover noise

·       Using specific body positions or breathing patterns believed to make it easier

·       Straining, squeezing, or forcing the stream

·       Holding urine for long periods

·       Using alcohol

Although these strategies feel necessary, they gradually narrow the range of situations in which urination feels possible, making paruresis generalize to additional situations.

Paruresis Treatment

The most effective treatment for paruresis is graduated exposure therapy - a structured repeated practice in increasingly challenging bathroom situations. In our clinic, we find that combining graduated exposure with ACT (Acceptance and Commitment Therapy) makes the treatment even more effective.

Treatment includes creating a clear plan – a hierarchy - to gradually attempt to urinate in different situations starting with those that feel the least challenging and progressively increasing difficulty over time. Treatment also includes fluid loading before exposure practice. This is done to increase the urge to urinate, making initiating a stream easier.

Whenever possible, it can also be helpful to involve a pee buddy — a trusted person with whom you feel comfortable. A pee buddy may stand nearby, wait outside the restroom or stall, enter the restroom together, or help recreate real-world conditions in a gradual way. For many people, practicing exposures with a trusted person can make the process feel more manageable and reduce avoidance early in treatment.

Can Paruresis Be Cured?

Yes. With structured exposure-based treatment, most people experience significant improvement, and many are able to urinate comfortably in situations that once felt impossible. The key is consistent, graduated practice rather than trying to force relaxation or eliminate anxiety first.

A typical paruresis treatment plan may include:

·       Assessment of how paruresis developed, how it changed over time, and what currently triggers it (both internal and external triggers).

·       Identifying current overt and covert safety and avoidance behaviours.

·       Psychoeducation about paruresis, including how safety and avoidance behaviours maintain it, and how fluid loading is used in treatment.

·       Learning ACT-based strategies to support motivation, willingness, and persistence during exposure practice.

·       Creating a personalised exposure hierarchy.

·       Identifying a reliable backup restroom for early exposure work.

·       When possible, recruiting a pee buddy – a trusted person who can support exposure practice.

·       Fluid loading prior to exposure.

·       Practicing exposure tasks between sessions, reviewing progress, and adjusting strategies as needed.

Why Paruresis Is Often Missed or Misunderstood

Paruresis is very common, but is underdiagnosed because:

·       People are embarrassed to talk about it

·       Many assume it’s a quirky habit or a personal flaw and don’t realize it’s a known and treatable psychological condition

·       Even if a person seeks help, health professionals may not recognise paruresis. People are often referred for medical tests that come back normal, without further explanation

Even when a mental health professional recognizes that this is an anxiety disorder, one key misunderstanding often remains: assuming that the person is fearful of urinating in the presence of others. The treatment (usually Cognitive Behavioural Therapy (CBT)) based on this assumption may include exposure exercises that miss the real fear, leading to little improvement. This leads to a lot of confusion and despair.

The problem is subtle but important: in most cases, the fear is not about urinating in the presence of others. It’s about NOT being able to urinate when others might be nearby. This nuance changes how exposure is planned and what the person is actually practicing. For this reason, it is important to work with a therapist who has specific knowledge and experience treating paruresis rather than treating it as generic social anxiety.

If parts of this felt uncomfortably recognisable, there’s nothing unusual or “wrong” about you. Paruresis follows a very consistent pattern, even though it can feel deeply personal and isolating when you’re living with it.

What keeps shy bladder going is not the bladder itself, but the way anxiety, pressure, and well-intended coping strategies interact over time.

Many people feel a sense of relief when they finally recognise their own experience in this pattern. Paruresis can feel deeply personal and isolating, but it is surprisingly consistent in how it develops and how it responds to treatment.

The encouraging part is that this also makes it very treatable. People often see meaningful improvement once the pattern is properly understood and addressed — even if they’ve been struggling for years.

For people who want support, working with a therapist who has specific experience treating anxiety disorders and paruresis in particular, can make the process more effective and straightforward.

Where to Start If This Sounds Like You

Shy bladder is maintained by avoidance and control. The way out is gradual, repeated practice in the situations you’ve been avoiding. Here is where to start.

14 Practical Strategies to Start Overcoming Paruresis

1. Rule out medical causes.

If you cannot urinate even when alone at home, or you have pain, weak stream, frequent small volumes, or other physical symptoms, get checked medically.

If you can urinate normally at home when alone but struggle mainly when others are nearby (or might be nearby), you’re likely dealing with paruresis.

2. Stop trying to control when you need to go.

It is very common for people with paruresis to try to restrict fluids - sometimes very aggressively. Fluid restriction feels protective. But drinking less, “going just in case,” urinating on a schedule, or emptying your bladder repeatedly before leaving home just keeps the paruresis vicious cycle going. As with all anxiety disorders, control is the problem, not the solution.

Start reversing this:

• Drink normally.

• Stop restricting fluids before outings.

• Stop “pre-emptive” urinating unless you truly need to go.

• Let your bladder fill.

A full bladder increases your physiological odds of success. Trying to urinate with low urgency makes misfires (not being able to pee) more likely and reinforces the shy bladder.

3. Only practice when you genuinely need to go.

Trying to urinate when your bladder is only half-full sets you up for unnecessary struggle.

Wait until your urgency is reasonably high before going.

Let your body work with you, not against you.

4. Drop the language of “success” and “failure.”

You either urinate or not. Both are part of practice. The goal of the treatment is not to win a medal for a pee performance, but to show up and continue practicing. If you pee in a public washroom - that’s amazing. And if you don’t - that’s just as much of a win as you learn that it wasn’t the end of the world and you can continue practicing next time.

5. Build a gradual exposure ladder.

Start with situations that are slightly uncomfortable but doable, then move up gradually.

Examples:

• Home bathroom with someone in the house

• Door unlocked

• Someone standing outside

• Quiet public washroom

• One person present

• Busier washroom

• Urinal instead of stall for guys

• Peak traffic settings (workplace, airport, game, concert)

6. Practice frequently and intentionally.

• Practice all the time. Ideally, several times per day.

• Stay in the situation long enough to let your nervous system settle.

• Repeat attempts instead of leaving immediately after a misfire.

• Track attempts and contexts to increase awareness of subtle avoidance.

7. Stop buffering the experience.

Common safety behaviors include:

• Running the tap

• Flushing repeatedly

• Using background noise to mask silence

• Choosing only isolated stalls

• Waiting until bathrooms are empty

• Using alcohol to “loosen up”

• Avoiding urinals entirely

• Leaving the moment you sense someone nearby

These behaviors temporarily reduce anxiety, but maintain it in the long run. Notice them and gradually remove them.

8. Intentionally increase “pressure” in controlled ways.

Once basic exposures improve:

• Go during busier times.

• Choose random stalls.

• Use different washrooms.

• Go right before meetings.

• Arrive slightly late and tolerate the discomfort.

• Practice when someone passes behind you.

• Practice with mild time pressure.

9. Expect inconsistency.

You may go easily one day and struggle the next. This is normal. Progress in paruresis, just like with other anxiety disorders is rarely linear. Do not interpret fluctuation as regression. Just continue practicing.

10. Lean into discomfort instead of negotiating with it.

The paradox of paruresis is that the harder you try to urinate, the harder it becomes.

Instead of forcing it, allow anxiety to be present. Let the “what if I can’t?” thoughts sit there. Resist the urge to escape and stay in the restroom without rushing out. That way, you are retraining your brain that bathrooms are not danger zones.

11. Reduce outcome focus.

When you go into the restroom thinking, “This better work,” you’re increasing performance pressure. Instead, shift to: “I’m practicing being here.” Concentrate on the process, not the outcome. Outcome follows process.

12. Involve someone you trust to be your pee buddy if possible.

Practicing with a partner — therapist, friend, or trusted person — can accelerate progress.

13. Normalize it.

Paruresis is far more common than people think. Many high-functioning, confident individuals experience it. It is just a learned fear pattern that can be unlearned.

14. Commit to daily life, not symptom elimination.

• Drink normally.

• Travel.

• Attend meetings.

• Go to concerts.

• Use the washroom when needed.

The most common mistake that we see in patients with any kind of anxiety, including paruresis, is that they wait for anxiety to subside before doing the things they want to be doing. But the goal is not to eliminate anxiety first. It’s the other way around, that is, to live and let anxiety recalibrate in the background.

If progress stalls or anxiety escalates significantly, working with a therapist who understands exposure-based treatment can make a meaningful difference.

To summarise:

• Paruresis is highly treatable.

• Avoidance makes it grow.

• Practice makes it shrink.

If you’re tired of planning your life around bathrooms, you don’t have to keep doing this alone. At Turning Point Psychological Services, we treat paruresis using exposure-based approaches tailored to each client. Reach out to get started.

In Short:

• Paruresis is a learned anxiety response, not a physical malfunction.

• Avoidance and fluid restriction maintain the cycle.

• Graduated exposure retrains the nervous system.

• Inconsistency during recovery is normal.

• With structured practice, it is highly treatable.

Frequently Asked Questions About Paruresis

Is paruresis the same as shy bladder syndrome?

Yes. Paruresis and shy bladder syndrome are two names for the same condition - difficulty urinating when others are nearby due to anxiety. Some people also call it bashful bladder or pee anxiety.

Is paruresis a medical problem or a psychological one?

Paruresis is not caused by a bladder disease or physical obstruction. It is a form of social anxiety that interferes with urination in specific situations, despite normal bladder function.

Why can I urinate at home but not in public bathrooms?

This pattern is typical of paruresis. The difficulty is triggered by pressure, awareness of others, or the possibility of being heard or observed - not by a problem with the bladder itself.

Does avoiding fluids or planning bathrooms actually help?

Avoiding fluids or carefully planning bathrooms may reduce anxiety temporarily. However, these strategies reinforce the belief that urination is only possible under specific conditions, which strengthens paruresis over time.

Does paruresis get worse over time?

It often does. As avoidance and safety behaviours increase, the difficulty can spread to more situations and begin earlier — sometimes even before entering a restroom.

What is the most effective treatment for paruresis?

Graduated exposure therapy is considered the most effective treatment for paruresis. Many people benefit from combining exposure with Acceptance and Commitment Therapy (ACT), which helps build willingness and reduce avoidance.

Do I need to know what caused my paruresis to get better?

No. Many people improve without identifying a single cause. Treatment focuses on changing the current pattern of avoidance and anxiety rather than analysing a past event.

Can paruresis be cured?

Yes. With structured exposure-based treatment, most people experience significant improvement, and many regain the ability to urinate comfortably in situations that once felt impossible. Consistent, graduated practice is the key to retraining the nervous system.

Can paruresis improve even after many years?

it can. Even long-standing paruresis can improve once the pattern is clearly understood and addressed systematically. People are often surprised by how much change is possible.

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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“Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.”

Viktor E. Frankl

What is Acceptance and Commitment Therapy (ACT)?

 ACT is a type of behavioral therapy that is becoming increasingly popular in the treatment of OCD, and there is a good reason for it. It is so easy to get entangled in endless obsessions and compulsions and to lose sight of what really matters to you. With ACT, you don’t have to delay living the life you want to live until your OCD gets better. ACT provides the compass that allows you to start taking steps toward being the person you want to be right away.

Life isn’t easy. It is full of emotional and physical pain, disappointments, rejections, failures, and losses. And as if these painful experiences were not enough, our minds tend to constantly ruminate about the past, worry about the future, beat us up for our mistakes, warn us about all kinds of real and imaginary dangers, and discourage us from taking healthy risks.  

Our minds throw all kinds of unwanted, intrusive thoughts at us and at times, these thoughts become very sticky. They pull us away from the present moment and into our heads.

According to ACT, our difficult thoughts and feelings are not inherently problematic. But when we let our mind’s constant warnings and admonishments hook us, we often neglect doing what’s important and instead, go for quick fixes to get rid of discomfort and pain. This may help in the short-term but leads to moving away from what truly matters to us in the long run.

When we take what our minds tell us too seriously, we tend to take one of the following destructive approaches: 

1.    We become consumed by our thoughts or emotions and engage with them by ruminating, arguing with them, or wasting time trying to figure out why we are having these thoughts or feelings and what they mean.

2.    We try to get rid of our thoughts or emotions by implementing all kinds of thought-stopping techniques, using mind-numbing substances or food, distracting ourselves, or avoiding triggering situations or people.

If the above strategies are our main ways of reacting to difficult thoughts, then we live most of our lives vacillating between autopilot and avoidance modes and miss out on what matters most – the present.

Unfortunately, all this accomplishes is signaling to our minds that these thoughts and emotions are “important” and “significant,” and our minds then “helpfully” generate more of them.

This is especially true if you have OCD. The more you try to get rid of unwanted inner experiences (thoughts, images, emotions, physical sensations, urges, or memories), the more they persist. You then increase your efforts to control the unwanted thoughts and feelings. But control is the problem, not the solution, and the more you engage in the struggle, the more you get sucked into the quicksand of your internal experiences.

 To help you get out of this endless struggle, ACT promotes developing psychological flexibility, whose core processes can be summarized as:

1.    Being present in the moment.

2.    Opening up to whichever thoughts and feelings come up without trying to fight them.

3.    Doing what matters to you and taking steps toward being the kind of person you would like to be.

With psychological flexibility, you lean into your discomfort with self-compassion and curiosity. You stop running away. This opens up a road toward the freedom to choose what kind of person you want to be in the moment.

When OCD has a grip on you, you react in a psychologically rigid way, which means that you have a very narrow range of responses to your obsessions – that is, you respond with either compulsions or avoidance. Responding flexibly, on the other hand, involves doing whatever you choose to do while making room for the obsession without engaging with it. When you respond to your thoughts and feelings flexibly, you notice them, allow them to be there, and continue taking steps towards whatever matters to you without resorting to compulsions.

ACT emphasizes that we don’t have control over our internal experiences, including obsessions (which are basically just garden-variety thoughts even though you have learned to perceive them as scary or disturbing). We do, however, have control over our actions. Therefore, the most workable approach is to let the obsessions come and go at their own time instead of wasting time and energy doing compulsions.

 ACT teaches us a very different way of being in the world. Instead of white-knuckling through life, it helps us move toward what is meaningful to us. It is a very empowering approach that allows us to do what matters without being consumed by whichever feelings and thoughts may show up.

 Instead of spending our days in between avoidance and autopilot modes and trying to mindlessly chase endless tasks and goals (many of them meaningless to us), ACT helps us move strategically toward what is really important with intention and purpose. 

To summarize, ACT will help you:

-       Learn to make room for your emotions and thoughts.

-       Choose what truly matters to you.

-       Take steps toward being the person you want to be and living the life you want to live while being strongly rooted in the present moment.

“And what if my compulsions stand in my way to this?” you may ask. Great question as your OCD will certainly attempt to sabotage your progress. Thankfully, ACT is a very practical, action-oriented therapy approach (that’s why it’s so aptly abbreviated as “act”). It will provide numerous practical skills to help you handle your obsessions and compulsions.

ACT vs ERP

You probably heard that the most effective treatment for OCD is ERP. So how does ACT fit into the treatment and how is it different from ERP?

ERP (Exposure with Response Prevention) is a specialised CBT approach that teaches people with OCD to face scary stimuli (external or internal) while refraining from performing compulsions.

 ACT is, by itself, an exposure therapy. As stated above, its main foundation is the ability to experience difficult thoughts and feelings without doing anything to get rid of them or letting them consume us, and instead, to flexibly choose to take value-driven actions toward our goals.  

One of the most important components of ACT is the willingness to experience uncomfortable internal experience and moving in the direction of our values.

So, in this way, ACT and ERP have a lot of similarity as both promote exposure.

One of the differences between ACT and ERP is that ACT approaches exposure as a way of taking steps toward the life that is full of purpose. So instead of just “tolerating” the scary thought or object and waiting for the distress to subside, an ACT therapist will encourage you to identify your values, establish value-driven goals, and take steps toward those goals regardless of what thoughts or feelings are showing up.

That is, ACT is an exposure therapy, but provides a much more fulfilling way to do exposure. You are taking steps to being the best version of yourself instead of just learning to endure your anxiety. You discover that you may feel anxious and still do the things that are important to you. Instead of doing the hard stuff for the sake of “getting rid of OCD,” you work toward something bigger, something that is deeply important to you. This makes your therapy work so much more meaningful and increases motivation to work hard toward recovery. 

While many ERP therapists track anxiety levels while doing exposure (they use SUDS – Subjective Units of Distress as a measurement), ACT therapists do not view anxiety levels as important and don’t track them. After all, anxiety, like every other emotion, comes and goes in its own time and we don’t have control over it. If anything, tracking your anxiety just brings more of your attention to it and makes you feel it’s important, sending your mind and body a message to produce more of it. Instead, ACT therapists may track things like willingness to experience whichever feelings show up and doing what is important. They may also track how effectively you were able to unhook from your intrusive thoughts, or how you are progressing toward your value-guided goals. This allows you to drop the struggle, to get out of the tug of war with OCD and to focus on what matters.  

In addition to never trying to encourage you to get rid of anxiety, an ACT therapist may actually encourage you to see your anxiety as helpful. We experience strongest emotions about the things we care about. And an ACT therapist will urge you to look which yearnings –-things that matter the most to you -- may be underneath your anxiety. These insights will help you channel your anxiety or other emotions in the right direction.

Exposure exercises in ERP are often driven by a certain topic and by the severity of anxiety (low to high). In ACT, however, the exposures are driven by what stands in your way of being the person you want to be and living the life you want to live. ACT helps people to be more motivated and engaged when practicing exposure.

Can OCD be treated with ACT only - without ERP?

First of all, who is asking this question – you or your OCD?

 Usually, behind this question is the desperate attempt to avoid facing your fears in ERP. Also, behind it is the assumption that your fears are different, special, unusual, impossible-to-control, realistic, shameful -- and that for you ERP won’t work. So, you are on a mission to find a treatment that is less scary. You may be secretly hoping for a treatment that will allow you to get away with continuing doing compulsions. You may have already tried all kinds of alternative therapies, anxiety-reduction techniques, self-help books, positive thinking, or trying to find that one charmed compulsion that would get rid of the obsessions once and for all.

This quest to find a magic way to get rid of difficult emotions is the essence of OCD and the only way to get over OCD is to accept that it’s impossible to get rid of your emotions forever, no matter how much you compulse.

 There is a lot of overlap between ACT and ERP. ACT without ERP, when done by a therapist with an in-depth understanding of OCD treatment, is very effective in the treatment of OCD.

 It is important to note, however, that it is crucial that the ACT therapist is indeed an expert in the treatment of OCD and has substantial knowledge about cognitive and behavioral principles in general, as well as the patterns that are specific for OCD. Usually, such therapist will have a very good knowledge of and experience with ERP. Such therapist, naturally, will use ACT as a way to practice exposures. When a therapist does not have a solid understanding of OCD’s sneaky ways, he or she may erroneously view rumination (a compulsion) as an involuntary thinking process, thus, confusing an compulsion with an obsession and creating wrong interventions. Or, such a therapist may miss numerous subtle mental compulsions that are so typical for most OCD types.  

When ACT is combined with ERP, the treatment is the most effective as it incorporates building a strong ACT-driven foundation and motivation for the treatment with focused ERP techniques. After learning ACT principals, people usually have a better understanding of how ERP works and what its purpose is (and no, its purpose is NOT to get rid of anxiety or obsessions. Its purpose is to learn to make space for your anxiety and instead of letting it push you around, do what matters to you without relying on compulsions to alleviate your distress. It’s not about learning to “tolerate” anxiety either. It’s about radically changing your relationship with anxiety, distress, fear, disgust, and other emotions and thoughts, as well as about willingness to do what’s important to you regardless of your emotions).

 In fact, if a therapist has a great understanding of OCD, then whether he or she provides an ERP treatment or ACT treatment, these treatments will be equally effective and will actually look very similar. In both approaches, the goal is to create and strengthen new learning pathways that compete with the previously learned pathways of fear.

So the answer is: Yes, you can treat OCD with ACT if your therapist is an OCD specialist (as opposed to being a “generalist”).  

 And the second part of the answer is: You will still need to face your fears, anxiety, uncertainty, “not right” feeling, discomfort, disgust, or whichever painful emotions currently compel you to do you compulsions. You will need to face the uncertainty of whether the thing you fear the most may happen. And incorporating specific ERP exercises into the treatment will make the treatment faster and more successful.

ACT vs CBT

CBT (Cognitive Behavioural Therapy) consists of the cognitive and behaviour parts of the treatment. While the behavioural  part of CBT is very similar to both ERP and ACT, there are significant differences in the cognitive part.

Both ACT and CBT address changing your thinking.

CBT does it through strategies such as challenging negative automatic thoughts, addressing cognitive distortions, and changing “unhelpful” thoughts to more “rational” ones.  

ACT therapists, on the other hand, would rarely encourage you to dispute your thoughts in any way. They will work on changing your relationship with your thoughts by learning to observe them, effectively unhook from them, and increase your flexibility of responses to the thoughts. In ACT, the content of a thought is not that important. What is important is how helpful would it be for you if you would allow that thought to guide your actions.

This distinction is especially crucial in the treatment of OCD. In OCD, the content of the thoughts is never the real problem. It’s the engagement with the thoughts, taking them seriously, being afraid of the thoughts – in other words, the process of being hooked by the thoughts is the driving force behind OCD. So, disputing the thoughts is just another compulsion.

ACT, therefore, is the therapy that allows you to step out of your struggle and break free from being a prisoner of your thoughts, rather than engaging in endless debates with them.

Have you tried Acceptance and Commitment Therapy for OCD? Are you considering trying it? Please share your thoughts and experience in the comments below.

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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Kristina came to therapy to process her relationship with Randy, her boyfriend of three years. She said that the relationship is generally good, but she can’t decide if they should get married. Kristina and Randy tried couples counselling where they worked on issues such as trust, attachment patterns, old traumas, common values and goals, intimacy, and communication.

Kristina liked the couples therapist but felt that even though she and Randy followed the therapist’s suggestions and practiced the strategies learned in therapy, she could never get rid of the constant feelings of doubt about whether Randy was “the One.” She decided to pursue individual therapy to try and dig deeper into the relationship and process potential underlying psychological issues so that she could have certainty whether marrying Randy was the right decision.

Kristina said that one of her biggest fears is looking back at her life many years later and realizing that she made a horrible mistake when she married Randy. SShe was also fearful that she may be missing some important information about her current relationship with Randy and could be basing her decision on incomplete information.

By the time Kristina came to treatment, she and Randy had been living together for two years. Overall, she felt that the relationship was going well. She and Randy had similar interests and got along great for the most part. But she wondered if “going well” was enough to make a lifelong commitment.

Sometimes, after watching a romantic movie, Kristina would catch herself wondering why she wasn’t experiencing the same overwhelming feeling of bliss, love, and passion that she saw in the movie and whether she was missing out on the True Love that the movie's heroine found. This made her ponder that maybe she was settling for the second best. She found this thought very unsettling.

Other concerns also made Kristina question her commitment to this relationship. There were several times when she looked at other men and found them handsome. Surely, she wouldn’t feel this way if Randy was her real true love? A few weeks ago, Randy kissed her, but she didn’t feel anything. This alarmed her a lot – could it be a sign that she wasn’t really passionate about him?

Kristina has read endless blogs and articles trying to find certainty, such as “10 Signs You Have Found Your True Love,” “Five Red Flags That Your Relationship Isn’t Working,” and “How to Know That He is the One.” But instead of finding the answer, she became even more confused and uncertain.

Kristina valued authenticity and commitment in relationships and felt that by making the wrong judgment, she would be responsible for ruining both Randy’s and her lives. She also felt compelled to constantly talk about her doubts with Randy, as well as confess to him every time she had a thought about another person being attractive. She noticed that while Randy initially tried his best to comfort and reassure her, he had become increasingly impatient with her confessions.

 Kristina has tried to compare her feelings for Randy to the way her best friends felt about their partners. But, again, instead of being reassured, these conversations only amplified Kristina’s doubts. Many of her friends told her that they were sure their partner was ‘the One’ because they strongly felt like it. And the ones that sometimes experienced concerns about their relationship were surprisingly undisturbed by those concerns, brushing them away as a normal part of the relationship.

At the first session, Kristina confided in her therapist that she often worries that there may be another person out there, the one who is her second half, the perfect match. And if she agrees to marry Randy, she will have to let go of the hope of meeting that person.

Kristina said that she always felt uncertain about her boyfriends in previous relationships. At times she felt that the uncertainty was unbearable, and she broke the relationships early on – but then, after initial relief, she found herself doubting if she had made the right choice, which led to a great deal of suffering.

Kristina said that these thoughts make her feel very guilty. After all, she and Randy have so many great times together, and he treats her very well. But she can’t imagine living the rest of her life with uncertainty. She is tormented by the endless “what ifs” and spends her days trying to figure things out and achieve certainty.

Kristina’s goal for therapy was to figure out once and for all if this relationship was meant to be. She was hoping that after looking deep into her feelings, together with the therapist she would find the answer to her concerns. Needless to say, she was stunned when the therapist told her two shocking things:

1.     She may never know for sure.

2.     She meets the diagnostic criteria for obsessive-compulsive disorder, with a subtype that is known informally as relationship OCD (ROCD).

What is ROCD?

In every OCD type, intrusive thoughts (obsessions) attack what the person cares about the most. OCD hits where it really hurts. In ROCD, the obsessions attack the relationship. Sometimes it’s the relationship itself that the person has obsessional doubts about (relationship-focused). And other times the doubts are about their partner’s physical, personality, or behavioural traits or characteristics (partner-focused) 

The person wants to know for sure whether they truly love their partner. They feel that they have to do everything to be certain they aren’t making a mistake. There’s a sense of urgency to figure it out.

The person then desperately tries to achieve certainty about the relationship by engaging in endless compulsions.

Even though ROCD most currently relates to a romantic partner, it can happen in any other significant relationship.

ROCD Obsessions

These are typical questions that an OCD brain throws at an ROCD sufferer:

• Am I in the right relationship?

• Is this True Love?

• Is my partner the One?

• Does my partner love me?

• How can I make sure I will never get divorced?

• What if I am unauthentic for choosing to continue to be in the relationship without being sure about it?

• I have to make a decision about staying or breaking up. And I have to make this decision ASAP.

• What if there’s a better-matching person for me somewhere out there?

• I have to know for sure that this relationship will last forever.

• What if my partner and I are not the best fit?

• Why did I find another person attractive?

• What if I’m not attracted to my partner enough?

• How can I know for sure that I am in love with my partner?

• What if I’m actually gay and am just pretending? (Or, in a gay relationship, - What if I’m actually straight and am just pretending?)

• Why do I keep concentrating on the flaws of my partner’s appearance?

• I will never be able to stop being bothered by my partner’s unattractive appearance features or mannerisms.

• What if I’m settling for second best?

• What if my partner is not good enough for me?

• What if my partner is not intelligent enough?

• What if my partner is a bad person?

• What if I’m in denial?

• What if I’m making a mistake?

• What if I’ll never be able to completely trust my partner?

• What if I’m leading my partner on and am, therefore, an immoral person?

• What if I will regret my choice of a partner in the future?

• What if others know that my partner isn’t good enough for me and are judging or pitying me?

• What if I will be embarrassed by my partner?

• What if I’m not good enough for my partner?

• What if I’m in the wrong relationship?

ROCD Compulsions

Compulsions are the things that people with ROCD do to get rid of their anxiety, distress, or fear. As you can see, they can be overt (external, visible) or covert (mental). Usually, most people will have both overt and covert compulsions such as: 

• Mentally reviewing all the good and bad times with your partner.

• Trying to figure out for sure if you are true soulmates.

• Asking friends and family how they feel (or felt initially) about their partners and comparing that to how you are feeling about your partner.

• Subtly (or not so subtly if the sense of urgency is high), steering conversations with friends toward discussing relationship issues so that you can engage in comparisons or find reassurance.

• Googling love stories and comparing them to your relationship.

• Comparing your past relationships to this one.

• Comparing your partner’s appearance, physical, emotional, social, or intellectual qualities, sense of humour, or achievements to others.

• Comparing your relationship to the relationships of the couples whose pictures you see on social media (do these couples look happier, more committed, or more connected than you and your partner)?

• Focusing on the flaws of your partner’s face, hair, body parts, or any other physical attributes.

• Focusing on your partner’s bad habits.

• Carefully watching how others react to your partner, trying to ascertain whether they may be judging him or her to reassure.

• Confessing to your partner that you are not sure if you love him or her, or that you saw somebody you found attractive on the street, or that you didn’t feel aroused sexually when you kissed, etc.

• Checking if you are sexually aroused by your partner.

• Having sex with your partner for the purpose of reassuring yourself that you are still attracted to him/her.

• Submitting yourself or your partner to all kinds of tests to achieve certainty about the relationship.

• Taking online tests and quizzes such as “Do I Really Love Him/Her?” of “Is He/She the One?”

• Creating your own tests in your head, such as “If he truly loves me, he’ll cancel plans with his friends,” etc. Proceeding to the next test regardless of the outcome of the previous test.

• Writing pros and cons lists of the relationship.

• Ruminating about all relationship-related things.

• Constantly monitoring/checking how you feel toward your partner.

• Using therapy to figure out if you truly love your partner.

• Breaking up with your partner due to the distress caused by the uncertainty.

• Watching romantic movies and comparing your relationship to the one in the movie.

• Avoiding committing to the relationship or making any long-term plans in the relationship.

• Avoiding intimacy or closeness.

• Avoiding watching romantic movies.

• Avoiding hanging out with single friends out of the fear that it may show you that that’s what you truly want

 But How Do I Know if My Partner is the One?

The short answer is – you may never know for sure. 

OCD will always make you question everything. And trying to figure out the “correct” answer is one of the most prominent OCD symptoms.

Accepting the uncertainty of the future is the essential step in the treatment of OCD. Most of us don’t know for sure at all times that the relationship we are in is the right one. Some people may FEEL that they know for sure. Some people also have the propensity to feel certain about things in general (for better or for worse). Others are just as afraid of the uncertainty as you are but choose to declare certainty to avoid feeling doubtful.

But feeling certainty clearly doesn’t decrease anybody’s chances of getting a divorce sometime in the future (as evidenced by divorce stats). Feelings are just feelings and don’t have much to do with reality and with future probabilities.

ROCD Treatment

The treatment for ROCD is the same as for other OCD types – a combination of Exposure and Response Prevention (ERP) and Acceptance and Commitment Therapy (ACT).

It may sound counterintuitive, but OCD is always driven by compulsions, not obsessions. The more you compulse, the more frequent and stickier your obsessions become. But when you learn to stop your compulsions, you step out of the tug-of-war with OCD and begin your recovery.

OCD pulls you into an endless chasing of the sense of certainty. But even if you can achieve some relief by getting reassurance or by avoiding external or internal triggers, the urgent “what ifs” always come back.

In ERP, you will learn to put yourself in situations that will trigger obsessions and stay in these situations without resorting to compulsions. This practice teaches your brain that the intrusive thoughts (obsessions) may come and go and you don’t have to do anything to get rid of them.

The exposures will be a bit different for every person as they will depend on the person’s specific obsessions, compulsions, and core fears.

Some Common Exposures for ROCD:

• Thinking about looking back at your life several years from now and realizing that you made an awful mistake and have wasted your life settling for the person who is not the right one for you.

• Carrying around a very unflattering photo of your partner and looking at it throughout the day.

• Focusing on the unflattering aspect of your spouse.

• Expressing feelings of love and commitment to the partner via texts, phone calls, notes, or conversations.

• Allocating time to reflect on the fact that there isn’t much we can do to prevent making a mistake.

• Watching a romantic movie and allowing the anxiety about not having a passionate enough relationship to be there without trying to get rid of it.

• Creating a script about never knowing for sure if your partner is the One and living your life in ambiguity. Then playing/reading the script often, letting difficult emotions come, and doing nothing to get rid of them.

  All of the exposures are accompanied by “response prevention,” which means that you learn to face discomfort without resorting to any compulsions to alleviate it, thus, breaking the vicious OCD cycle.

The Choice

While your OCD may be screaming at you to remove all the uncertainty ASAP, the reality is that you have very little control over your intrusive thoughts and feelings, including the ones about uncertainty. Intuitively, you know this already. You have been spending your days trying to either figure things out or get rid of the thoughts. You know that the thoughts and feelings always come back and the more you try to achieve certainty, the more doubt you feel.

Nevertheless, you probably continued engaging with your obsessions hoping that you will finally find THE ANSWER and then everything will be fine, you will be sure, and you’ll live happily ever after.

You have been trying to dig yourself out of the hole for a long time. And the more you are invested in your digging, the deeper you dig yourself in. Ask yourself, have you ever found anything that your partner said or did that has resolved your doubts for good? Or, have you ever felt absolutely over the moon in love with your partner 100% of the time? If yes, then why are you reading this article? And if not, then are you really willing to spend the rest of your life in the tug of war with your obsessions?

The definition of insanity is to continue doing the same thing over and over again while expecting a different result. So how about doing something radically different for a change?

The sooner you accept that no amount of effort can help you permanently get rid of your obsessions and doubts, the faster you can be on your way to recovery. You don’t have to like your obsessions, but you need to come to terms with the fact that they will come and go in their own time regardless of whether you are doing anything about them.

When another “what if” thought comes, notice and acknowledge it – “Oh yeah, here’s another doubt” or “I’m noticing that I’m having a thought about whether this relationship is forever.” Even though you’ll feel compelled to engage with the thought by either trying to figure it out or push it away, try to instead gently unhook from it. Observe it with curiosity and then reconnect to the present moment.

So, we agree (hopefully) that you can’t control your thoughts and feelings. What CAN you control then?

You have full control over the kind of partner you are CHOOSING to be in your relationship.

Instead of desperately trying to make THE RIGHT decision, you need to make A decision and then take the steps toward making it right.

When you give up the pursuit of certainty, you can choose to just BE in the relationship. Does it mean that the relationship is for sure the right one? No, of course, it doesn’t. But you can decide that you are not willing/ready to leave, say, for the next six months (make it three months or even three weeks if it’s easier). Unless your relationship has some severe problems such as abuse or very obvious, extreme incompatibility, give yourself permission to spend these six months practicing being the best partner you can be – whatever this means to you.

How would you act if you were sure of your love for your partner? What kind of partner would you want to be in a relationship? Maybe you value being caring, kind, compassionate, fun, authentic, engaging, patient, sexual, or supportive? Maybe you want to be the one to initiate things? Act “as if.” Write a love note to your partner. Talk about the future. Keep bringing your partner to your family events. Take the next six months to practice taking steps toward these values and then, if needed, after the six months are over, take an hour to consider if you are leaving or staying for another six months.

Your OCD will tell you that this can’t wait. It will urge you to figure things out before you ruin your life. It will ask you just to look deeper. It will push you to seek reassurance. Remember – all of these thoughts are obsessions. It doesn’t mean they are either true or untrue. You can allow them to come and go while you are making a choice TO BE IN THE RELATIONSHIP instead of living in your head. If you let OCD dictate how you live your life, you’ll continue to spend your time evaluating the relationship instead of being in the relationship and experiencing it in real time. You will continue to miss out on the relationship and on life.

Take this time period to practice being present in your relationship and to be the best partner you can be. Take this time to also refrain from discussing the relationship, confessing, testing, ruminating, and all the other compulsions. Avoid doing these with your partner, family, friends, the therapist, and yourself. Just be.

Will any of this help with figuring out for sure if you are with the One? Nope. Will it help you be on your way to recovery from OCD? You bet!

Think you or your loved one may have an ROCD? Share your story in the comments below!

If you enjoyed this article, follow us on Facebook for more great tips and resources

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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“I don’t know if I should continue therapy,” announced Linda after spending a couple of minutes in a reflective silence at the beginning of the session. “What’s the point of all this? We all are going to die anyway. No amount of therapy will give any meaning to my life. It’s all useless.”

Ian, a gifted, over-achieving teenage boy has lately fallen behind at school. He finds it impossible to concentrate on anything except finding the answer to the question that haunts him day and night: “How can I know for sure that I really exist? What if somebody is just manipulating my brain and creates the illusion of my experience?” Ian feels that until he can be certain that his experience of life is real and is not created artificially, he can’t continue his regular daily life. He sometimes pinches himself trying to discern his perception from reality, but then he realizes that his perception of the pain may also be artificially created. He also stares at the mirror trying to figure out if the reflection is really his. But again, he feels there’s no way to know for sure. He keeps asking his parents if he is real and if they are real, but he is never satisfied with their answers. “Their claims that all of us are real can also be pre-programmed or manipulated,” he says.

Zoran, a 23-year-old university student has always been preoccupied with philosophical matters. His parents encouraged it and as a family, they engage in intellectually stimulating discussions about the nature and meaning of life. Gradually, though, his parents started to notice that Zoran’s goal in those discussions was to reach a conclusive answer to his unanswerable questions. They also started to notice that these discussions often caused Zoran increasing distress when they discussed the uncertainty of the topics. The parents then tried to stop these philosophical debates, but Zoran became very angry. He followed his parents around the house and demanded that they answer his philosophical questions and listen to his monologues of philosophical quandaries.

Down the Philosophical Rabbit Hole

 Many of us have questions that can’t be answered. Philosophers, writers, and poets devoted their lives to pondering such questions. But sometimes, these philosophical quandaries feel endless, pervasive, and torturous, and often interfere with a person’s ability to enjoy life. This is a cue that the person consumed by them may suffer from existential or metaphysical OCD.

Existential OCD is characterized by searching for answers to unanswerable, abstract queries. If you have this kind of OCD, you may be preoccupied with the philosophical aspects of life. You may feel that it’s impossible to continue living until you find an answer to your unresolvable questions. The constant fixation on philosophical or mystical issues most likely leads to incredible distress and interferes with daily functioning.

This OCD type is often mistaken for genuine interest in philosophy. Teachers, university professors, family members, friends, and therapists frequently inadvertently contribute to the worsening of this type of OCD. They indulge the OCD sufferer by engaging in deep intellectual discussions. But for the person with OCD, this endless quest for answers is a source of unbearable pain, frustration, fear, exhaustion, and, often even depression. Even if these discussions achieve some temporary alleviation of pain, in the long run, they just lead to an increase in obsessions and doubts.

Obsessions typical for existential OCD:

-       What is the meaning of life?

-       What if there is no meaning to life?

-       What is my purpose?

-       What is life’s purpose?

-       Am I real?

-       Are you real?

-       Is our life real?

-       How do I know that the world around me is real?

-  What if reality doesn’t even exist?

-       Is this conversation that we are having real?

-       How do I know that me, is really me?

-       How do I know that this is not a simulation of reality?

-       Why are we here?

-       What if I don’t really exist?

-       What is my true calling?

-       What if all of this is happening in my dream?

-       Are we really here in the room right now?

-       We will all die, so what is the point of anything?

-       Is the person I see in the mirror really me?

-       What if all of this is staged?

-       What is reality?

-       What if we are just pawns in somebody’s game?

-       What if my life is actually somebody’s video game?

-       What if I am in a coma?

-       Are my sensory perceptions the same as the other people’s?

-       What if my brain is held in a jar and is manipulated by somebody?

-       What if I’m the only conscious person on the planet and everything else is a pre-programmed character/ an npc?

-       What if all the people that I care about and love are not real?

-       What does it mean to be my true, authentic self?

-       What is my true identity?

-       Compared to the vast universe, we are all just meaningless specks. What if there is no point to our lives?

Typical Compulsions for Existential OCD:

As with all the other OCD types, the compulsions are directed at reducing the distress caused by the obsessions and attemps to achieve certainty. They are aimed at resolving the problem, finding out the answer, figuring it all out, or at least, avoiding the triggers or neutralizing the anguish.

-       Researching and reading philosophical, psychological, or theological books, blogs, and online forums trying to find the answers to the unanswerable questions.

-       Constantly questioning reality.

-       Mentally reviewing your days trying to see if they felt real.

-       Engaging others in conversations about the meaning of life or about what is real and what is not. This is usually done under the pretense of just being curious about the subject.

-       Trying to mentally figure out the answers to your existential questions.

-       Avoiding triggering movies, such as The Truman Show, The Matrix, or Inception, or TV shows addressing philosophical topics.

-       Ruminating on existential topics.

-       Taking philosophy courses with the goal of finding answers to your questions.

-       Trying to distract yourself.

-       Trying to find physical evidence that the world around you is real and/or that it’s not staged.

-       Trying to find physical evidence that you exist (looking in the mirror, pinching yourself, monitoring your physical sensations).

-       Constantly looking for reassurance (asking friends, family members, clergy members, researching, watching YouTube, etc.).

-       Asking family members if you are real.

-       Asking family members if they are real or if the other family members are real.

-       Disconnecting from the moment and interpreting it as an alternative “experience.”

-       Checking to see if you’re “in control” or if someone is controlling you.

-       Comparing how you feel now to how you felt in previous moments or to other similar situations to see whether it’s a real feeling or not. 

-       Looking for déjà vu experiences and interpreting them as the evidence of reliving the past, which means that the present may not be real.

-       Thinking about causing pain to a family member to see if they feel the pain to ensure they are real.

-       Mentally reviewing the evidence trying to find an answer to the obsessive question.

The Difference Between Existential OCD and Regular, Non-OCD-Related Philosophical Interests

 Like with other OCD types, people with existential OCD often question whether they have OCD or if they are just inquisitive about issues related to the meaning of life. The hidden function of this questioning is usually to find a justification to continue doing compulsions, as stopping them (that is, accepting that there is no definitive answer to the existential questions) seems too scary. In fact, this questioning is, by itself, another obsession (“What if it isn’t OCD and by stopping my research, I will be left with unanswered questions forever and will never be able to live a normal life?” – or some other variation of this question.)

This type of questioning is not any different from trying to justify other types of OCD. For example, people with religious scrupulosity OCD may insist that they are just spiritual people, or people with relationship OCD (ROCD) may claim that they simply value relationships, people with real event OCD may maintain that they just want to find closure, and people with illness anxiety may insist that they just want to be prudent in taking care of their health.

Point is, pretending not to be OCD is one of OCD’s most insidious lies.

So, what is the difference between an OCD sufferer and a philosopher?

As with all other OCD types, it’s not the content of the thoughts that determines whether it’s OCD, but the process of how you relate to the thought.

People who are interested in philosophical subjects and who don’t have OCD usually enjoy learning about this subject. They live their regular day-to day life without being tormented by intrusive thoughts. They don’t have an overwhelming sense of urgency to figure things out and they don’t feel incapable to live with uncertainty.

OCD sufferers, however, often find the research and examination painful and feel unable to stop. For them, research is not driven by curiosity, but rather by the burning need to alleviate their discomfort caused by their existential obsessions.

Here are some signs that your philosophical dilemmas are likely driven by OCD:

-       Your thoughts cause you a lot of distress.

-       Sometimes you feel proud for being such a deep person who is concerned with profound matters of life, death, and meaning. But most of the time, these thoughts lead to a great deal of suffering and the questions and the attempts to answer them seem endless.

-       Your “why” questions always lead to more “why” questions in an infinite, unresolvable stream of thinking.

-       You are desperately trying to get rid of your thoughts by seeking reassurance, distracting yourself, avoiding triggering topics, neutralising the thoughts, and trying to think positively.

-       You feel that you just have to find the definite answer to your un-answerable thoughts (as opposed to simply being curious and exploring the subject without the need to find an answer).

-       You spend a lot of your time ruminating about these unresolvable matters.

-       You get lost in these thoughts and feel unable to unhook and get back to the present moment. 

-       Your attempts to find answers are time-consuming and interfere with living your life.

-       You experience a sense of urgency to find answers and certainty once and for all.

-       You feel that you are unable to enjoy life until you figure things out.

-       No amount of information is enough.

-       No amount of reassurance is enough.

-       You find yourself going deeper and deeper down the rabbit hole of the Internet trying to find relief.

-       You just have to know for sure!

If you’re still unsure whether it’s OCD, it is always a healthier approach in any case of doubt to err on the side of caution and deem your thoughts as OCD and treat them as such.

Treatment of Existential OCD

As with all OCD types, it’s not the obsessions that keep OCD going, but the compulsions.

Obsessions are usually accompanied by a very strong feeling of fear, anxiety, or distress. Compulsions are an attempt to decrease that feeling. The more you resort to compulsions, the more you are teaching your brain to generate additional, sticky intrusive thoughts. By compulsing, you are sending the message to your brain that the questions it produces are important and urgent. You are also learning that compulsions are the only way to obtain relief and thus, you resort to performing more and more of them.

Since compulsions make OCD stronger, the goal of OCD treatment is to teach you that you can experience obsessions and do nothing about them. In other words, to stop the compulsions. You can learn to have these thoughts, let them come and go, and continue living your life in the present without dropping everything in order to figure your obsessive thought out.

The best treatment for OCD is a combination of Exposure with Response Prevention (ERP) and Acceptance and Commitment Therapy (ACT).

The treatment will help create new pathways in your brain where you don’t compulse, in spite of having the obsessive thought.

 Some Exposure Exercises for Existential OCD:

-       Watching triggering content on TV or YouTube (if you have been avoiding it). Movies such as The Matrix, Inception, and The Truman Show are great existential OCD exposures.

-       Staying away from any philosophical literature if you’ve been compulsively reading it (OR reading philosophical texts if you’ve been avoiding them).

-       Saving or screenshotting news headlines about mystical occurrences, life after death, living in a computer simulation, or UFOs and looking at the screenshots on your phone throughout your day.

-       Reading news articles or watching clips about unexplained occurrences and phenomena.

-       Creating a screensaver on your computer or your phone that says, “You may never ever find out…”

-       Writing on your mirror: I may never know for sure…

-       Creating scrips about potentially never finding out what the meaning of life is.

-       Creating scripts about perhaps never knowing for sure whether you are real or not.

 The scripts may address a scenario of spending your whole life not knowing. Or looking back at your life on your deathbed and still not knowing. Or never really figuring out the true meaning of life. Or finally realising that life has NO meaning. Basically, the script can involve any content about learning to live with uncertainty. Again, the goal of the scripts is to learn to face your fears without resorting to compulsions.

As stated above, the most important part of doing the exposures is to combine them with response prevention (that is, facing the scary scenarios without doing anything to try and alleviate the uncertainty or discomfort).

A Warning About Ineffective and Potentially Harmful Treatment

Beware of a therapist that will give the content of your OCD thoughts too much attention.

A therapist who does not have in-depth knowledge of cognitive and behavioral processes that underlie OCD may engage with you in discussions about your existential questions. Such a therapist may also try to reassure you. Or, he or she may attempt “cognitive restructuring” by exploring your thoughts, examining the evidence that supports or disproves them, seeing how they may relate to your core beliefs, or coming up with some more “realistic” or “positive” thoughts.

All this may make you feel better for a short time, but these discussions are nothing but compulsions. You will likely find yourself questioning the discussion that happened in the session and coming up with more questions and concerns. So, choose your therapist wisely.

16 Steps You Can Start Taking Today If You Have Existential OCD:

These steps will help you gradually reclaim your life by learning that you do not have to waste your time compulsing. You can live with your questions, with your uncertainty, and without knowing. Instead of compulsing, you can concentrate on being the person you want to be even if you never figure out the answer to your OCD’s questions.

1.     Take an inventory of what you have lost to OCD so far. How has being in your philosophical head affected your relationships? Your work or studies? Your health? Your joy?

Write these things down and use them to motivate you on your journey to recovery.

2.     Reflect on your past attempts to figure things out. Have you found a strategy that has led to the permanent disappearance of your obsessions? If you haven’t – time to give up trying and stop wasting your time.

Acknowledge that you have spent more than enough time trying to find THE ANSWER. Make a choice to try a different strategy.

3.     You have done a lot of things to find the answer to your questions and know for sure. How about concentrating on living with not knowing? It is difficult, yes. And yet it is the only way to live this uncertain life. You are living with uncertainty in every other area of your life. We can only really be in the present moment (and not in our head) if we give up the hope to find certainty.

4.     Remember that even though the content of your obsessions may seem different, unique, or special - in reality these are just thoughts and they are not unlike any other thoughts that your brain generates. It’s giving these thoughts special attention and treating them as important and urgent that drives your OCD.

5.     Develop a habit of noticing your thoughts and the way they hook you. Take a step back and say to yourself, “Hey, here’s another one of these thoughts.” “Here’s the familiar sense of urgency.” ”I notice an urge to check/figure out.”  “Here’s my meaningless life story.” Do nothing about these thoughts. Observe them with curiosity without engaging with them.

6.     Practice sitting with the difficult feelings that are connected to your obsessions and do nothing to get rid of these feelings. Practice letting these feelings come and go at their own time without trying to MAKE them go. Do it regardless of how distressful and difficult the feelings are. Just let them be.

7.     Stop reading and researching anything related to existential topics.

8.     Tell your family members and friends that you are working on getting your life back and explain that they need to stop engaging in philosophical discussions with you, even if you beg them to do so. Create a code word or a code sentence that they can reply with when you ask them philosophical questions. For example, they may say, “I love you and that’s why I don’t want to engage with your OCD.” Or, “it seems your OCD is tricking us into entering the rabbit hole again.” Encourage them to respond (lovingly and patiently) with these words/sentences instead of being sucked into another discussion.

9.     Make a similar agreement about reassurance. Ask your family members to respond supportively, but firmly each time you ask for reassurance. They may say, “I don’t know the answer to this. I get that it’s hard, but we can live with not knowing.”

10.  Limit yourself to a certain number of reassurance-related questions per day or per week and work on gradually diminishing this number. Use these reassurance coupons and do not exceed the agreed-upon number of coupons for the week.

11.  Watch distress-inducing movies that you have been avoiding. Do nothing to try and reduce the distress.

12.  Take some index cards. Write your existential questions on one side of the cards. On the other side, write: “I may never know.” Carry these cards with you. You can also give these cards to your family members if you tend to ask them these questions. When you ask the question (again) the family members can show you the question written on the card, and then the back side of the card with “the answer.”

13.  Stop ruminating. That is, stop trying to find the answers in your head by mentally reviewing the information, trying to figure things out, checking, and otherwise attempting to find a solution to your obsessions. Remember, rumination is not the same as having your initial obsessive thought. You don’t have control over the thoughts that pop into your head (obsessions). But you do have control over whether you are choosing to engage with them (rumination).

14.  Learn to live with not-knowing. You may never know. Make a script about not knowing.

15.  Engage in Life! Bring your full attention to the things that matter to you and make a choice of taking steps toward the life you want to live and the person you want to be. You don’t have an answer right now. Maybe you’ll somehow find the answer in the future. Or maybe you never will. Regardless, you can choose to be the best version of yourself at this very moment.

16.  If you can, find an OCD specialist who can help you build the foundation for OCD treatment via ACT strategies, structure your ERP, and guide you toward recovery.

Think you or someone you know may have existential OCD? Share your story in the comments below!

If you enjoyed this article, follow us on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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My OCD is Different

It happened years ago. You even forgot about it for a while, until you remembered and all of a sudden, it hit you and now you can’t stop thinking about what you’ve done. You spent hours researching how to get rid of the shame and guilt about something you did in the past. Your friends and family told you to get over it, that it wasn’t a big deal. You’ve spent years convincing yourself you didn’t do anything wrong. You’ve replayed it in your head countless times. And yet, none of it seems to relieve your intense guilt

While obsessively Googling (again) and asking questions in online forums, you may have stumbled upon information related to OCD and its symptoms.

It seemed that what you are experiencing is very consistent with having obsessions and compulsions. But then – how can that be OCD? After all, you have read that people with OCD are constantly worried about something bad happening in the future. And that they are unlikely to do what they are afraid of doing. Your case, however, is very different as you actually DID do what seems like an immoral or horrible act.

So it can’t be OCD, right? But if not, then what is it? And how do you step out of this never-ending struggle of trying to find reassurance and get rid of the horrible guilt feelings? How do you move on with your life?

And how to know whether it’s OCD or not? 

Doubting that you may have OCD is a common OCD symptom. This is one of the lies that OCD tells you, and in no other type of OCD is this lie as effective at hooking you as in real event OCD.

OCD is a doubting disorder. It will make you doubt your memory, your recollection of things, your morals, your intentions, your identity and – that’s right –whether you even have OCD! As it would have you believe, maybe you are just a horrible person who uses OCD as an excuse to avoid paying the moral price for your past misdeeds.

Some Examples of Past Events That People with Real Event OCD Tend to Ruminate about:

-       I stole someone’s work idea and presented it as my own

-       I bullied a kid when I was in school

-       I was really mean to a friend

-       I cheated on my partner

-       I engaged in a sexual play with my brother when we were kids

-       I broke up with my girlfriend in the worst possible way

-       I cheated on an exam/assignment

-       I had sex with a girl who didn’t seem 100% sure about having sex with me

-       I abused my sibling

-       I made a racist remark at a co-worker

-       I drank and drove

-       I made a fraudulent claim when submitting taxes

-       I was involved in a mean prank on friends

-       I made a horrible mistake and my life will never be the same because of it

Common Real Event OCD Obsessions 

-       Intrusive thoughts, images, memories, and flashbacks about what happened

-       Intrusive thoughts and worries about being immoral, bad, mean, sick, racist, deceitful, cruel, hypocritical, despicable, unauthentic

-       Thoughts about needing punishment for your actions

-       Overwhelming feelings of guilt or shame

Common Real Event OCD Compulsions 

-       Mental review

-       Trying hard to figure out what exactly happened, why it happened, and what it says about you as a person

-       Trying to recall all the little details of the event (while constantly questioning the accuracy of your recollection)

- Replaying the event in your mind again and again

-       Confessing

-       Seeking reassurance

- Self-reassurance

-       Ruminating

- Trying to rationalize

-       Googling topics that are related to the event

-      Googling how other people overcame a similar event

-       If you harmed another person, following that person on social media and trying to get information about them in an attempt to find out if what you did continues to negatively affect their life

-       Trying to achieve 100% certainty in remembering what happened

-       Reading about ways to forgive yourself

- Trying to block or neutralize the thought

-       Asking others if you are a good person

-       Reading about what it means to be a good person

-       Trying to prevent doing something bad in the future

-       Trying to distract yourself

-       Excessive self-reflection

-       Avoiding anything that can remind you about the event

- Avoiding the place where the event happened (or, on the opposite, going back to that place trying to recreate the event in your mind or to check how you are feeling

-       Debating whether to search for the person you harmed and apologize or to stay away

-       Asking others for their opinions

-       Asking others if something like that ever happened to them

- Coming up with scenarios of a similar event happening in the future and trying to figure out with absolute certainty that you will behave differently then

-       Trying to “neutralize” the disturbing thoughts by reassuring yourself that you are a good, moral person

-       Punishing yourself

-       Cultivating self-hate in an attempt to relieve the guilt

-       Trying to repent by doing “good deeds”

Of course, like with every single other OCD type, the more you seek certainty, the less certain you become. And while the compulsions may sometimes bring you temporary relief, in the long run, they just lead to stickier obsessions.

How Do I Know if It’s Really OCD?

These events aren’t something that anybody would be proud of, but most people find a way to continue living their lives in spite of their regrets and remorse. In your case, however, you feel stuck and are unable to get over what happened. You question your identity and feel you don’t deserve to move on until you find a way to figure everything out and make amends.

Real event OCD, as well as false memory OCD described below, is very commonly present in combination with all kinds of moral, scrupulosity, and harm OCD, and, specifically, with pedophilic OCD (POCD) and sexual orientation OCD (HOCD).

As with every OCD type (and there are many more commonalities between all the OCD types than differences between them), it’s not the nature of the event that determines if it’s OCD or not. It’s the process of your engagement with your thoughts that indicates that it may be OCD.

Here are some signs that you may have OCD:

-       You are overwhelmed by uncertainty about what really happened, how it may have affected you or others, and what kind of person you are. This uncertainty feels unbearable and leads you to seek ways to get rid of it and figure out once and for all, with 100% certainty what happened.

-       The uncertainty may be related to:

• Specific details of what happened

• Long-term impact on the other person or people

• Doubts about whether you are a bad or good, moral or immoral person

• Wondering if you can move on with your life or need to continue self-punish

• Fears that you may have committed more offensive or inappropriate actions, but just don’t remember them

• Wondering if the intrusive thoughts and images will ever go away

• The need to know if it really is OCD or if you are just looking for excuses for what you did (more on this below)

• Wondering if what happened in the past may predict more wrongdoings in the future and how to make sure to prevent them

-       You feel that you can’t move on without figuring it all out

-       Your thoughts are very sticky, and you are preoccupied with them

- You have a sense of urgency to do something about the event right away

-       A great deal of your day is dominated by your thoughts and feelings, as well as by your attempts to “deal” with them

-       Your daily functioning (work, studies, relationships, hobbies, self-care, motivation, etc.) is negatively affected

-       You find yourself in a never-ending quest to find relief, but the relief is always short-lived and additional doubts and questions seem to be constantly generated by your mind

-       The more you try to figure out your past, your future, and what kind of person you are, the more doubts you have

Now, to go back to the beginning of this article – you are probably skimming through this page with an urgent question in mind: HOW DO I KNOW FOR SURE IF IT’S OCD?  

Please brace yourself for an answer: Your question by itself is an OCD symptom – a desperate need to have certainty. You think that if only you knew for sure that it’s really OCD, then you could forgive yourself and move on. But the thing is – like with every single one of OCD’s questions – you will never know for sure. It’s this quest for certainty that keeps your OCD going. And the only way to recovery is by accepting the uncertainty. None of us know anything for sure. And you are not special in that way. You may never know for sure either.

So, the answer to your question is: You may never know for sure and making peace with this not-knowing is your first step to regaining your life.

Here are a couple of other similar and not well-known OCD types related to past events:

False Memory OCD

A person with this OCD type may be unsure if they did or said something bad or immoral. It is usually related to a specific, neutral time or event after which the person starts doubting if maybe, during that time, they somehow did something bad, said something insensitive or insulting, left an offensive or racist comment on a social media post, or messaged or emailed something inappropriate.

Another possible manifestation of this OCD type may be a person doubting if they were the ones who committed a high-profile crime that happened in their area. On the one hand, the person knows that he or she didn’t do it, but on another level, there is a doubt - what if they somehow did it and just blocked it from their memory.

In this case, the person is not sure if anything actually happened or not, but the possibility that something COULD have happened drives the compulsions.  

Of course, exactly like in the case of Real Event OCD, no amount of mental review (or physical checking), rumination, or reassurance is enough to relieve the uncertainty. And the more the person thinks about it, the more real and detailed the false memory feels. In time, it actually does become a memory of its own - shaped and embellished by numerous retrievals. The more the person ruminates about it, the more OCD will "fill in the blanks" of what supposedly happened.

The false memory (the obsession) and the attempts to figure out whether the event happened (the compulsions) create a vicious cycle where the more the person ruminates, the more real the memory seems. And the more real the memory seems, the more compelled to ruminate/review/figure out the person feels, which, in turn, leads to the memory seeming even more real.

Life Editing OCD or Memory Hoarding

This is the need to record and document everything that is happening in a person’s life. It’s a kind of mental hoarding where the person feels compelled to “collect” their memories in case they will need to retrieve them with 100% accuracy someday. They feel that if they don’t “save” the memories very accurately, the memories may get fully or partially lost, distorted, or misconstrued. A person may try to memorize an event, an inter-personal interaction, or the details of their environment.

Of course, with these other two OCD subtypes, exactly like with real event OCD, the attempt to get absolute certainty about the past leads to more and more doubt.

There is a huge overlap between the compulsions among all these OCD types and, in general, among all OCD types. Real event OCD and false memory OCD are especially related to moral scrupulosity (and, thus, to ROCD, sexual-themed OCD, and harm OCD).

What You Can Start Doing Right Now to Deal With Your Real Event OCD

As with all OCD types, it is not the obsessions that drive your OCD. The obsessions are just the thoughts that are generated by your mind. When you engage in compulsions, you are sending your mind the message that these intrusive thoughts are important and the mind then, in turn, generates even more of them. 

Here are some strategies for you to start breaking free from being pushed around by your obsessions:

1.     OCD is known for attacking what matters the most to us, so this is your chance to use your obsessions as a guide to understanding yourself.

Which values lie underneath your regret? What is your pain trying to tell you? What matters most to you in your life? What kind of person would you like to be? How would you like to treat yourself, others, and the world around you?

As opposed to to being consumed by your intrusive thoughts, memories, and emotions, use them to uncover your core values and start taking active steps toward them in the present instead of being consumed by the past.

2. Start making a list of what gets neglected while you continue being entangled in the battle with your mind. Is being consumed by the past preventing you from having a present? Do you find that being hooked by your thoughts prevents you from taking effective action toward your goals? Are you spending so much time in your head that you don’t feel present or engaged in the moment with people you care about and in doing what you love? What would you be doing differently if you could put your memories aside and reengage with what matters to you in your life?

Make a list, put it somewhere visible, and use it for motivation in the moments where your OCD tries to hijack your attention by making you compulse.

3.     Every time you have an urge to check, ruminate, neutralize, reassure, or do any other compulsion – ask yourself, “If I let these thoughts and emotions determine what I do in the next few minutes or an hour, will it get me closer to the person I want to be or will it move me even further away?”

You have to make a choice here: do you move toward your values, or toward your compulsions? It can be one or the other – never both. Practice making choices that serve you and not your OCD.

4.     Put a visible reminder somewhere that it’s OCD that is your enemy now, not your past event.

5.     Do not try to get rid of your thoughts and emotions. They will come and go at their own time. Let them be and redirect your attention toward taking a step toward something that is important to you (not to your OCD). Don’t wait for the difficult emotions to subside. You can have them and still live your life the way you choose to in the present.

6.     Ban rumination. This is a very insidious compulsion that masquerades as problem-solving.  Even trying to figure out whether it is really OCD is an example of rumination.

As just stated, there is no point in trying to get rid of your initial thoughts. The more you try to get rid of them the more attention you are giving to them. But engaging with the thoughts (as in ruminating) is a whole different issue. It may seem automatic and involuntary to you now. But the good news is that with practice, you can learn to redirect your attention elsewhere.

Think about your intrusive thoughts as spam emails. There may not be much to do to stop them. But you don’t have to open them, read them, respond to them, or spend time thinking about them.

Your intrusive thoughts thrive on your attention. Whether you try to debate them, prove them wrong, examine them, get rid of them, discuss them, confess them, get deeper to their meaning, worry that you’ll never be able to stop them, or whatever else you may be doing, — all of it just makes them stronger. Instead, start noticing them and redirect your attention elsewhere. It doesn’t matter where. You don’t even have to redirect your attention to anything specific, you can let your attention wander — as long as you do not direct it to the obsessive thought.

In the beginning, it will be difficult. But you will soon learn that you have much more control over your attention than you realized. And while you will still be aware of your intrusive thought (we are not trying to get rid of it, remember?), it will remain somewhere at the background while you go about your life without engaging with it.

7.     Practice self-compassion. This is not the same as forgiveness (which, in your case, most likely will just constitute another compulsion).

Self-compassion is acknowledging that you are suffering. You can remind yourself that suffering is a common human experience and is a part of life. Give yourself a moment of kindness without reassuring yourself. Put a hand on your heart and say to yourself, “This is very hard. This causes me a lot of pain. I have such a strong urge to do a compulsion.  I am allowed to be kind to myself.”

(Yes, yes, I know: your OCD will probably tell you that you don’t deserve kindness. Or that kindness is another way to trick yourself into thinking you didn’t do anything wrong. Please treat this thought just like every other obsession – let it be and continue practicing self-compassion)

8.     This is a tough one. The only way to recover from OCD is to be willing to live with the fact that your scary thoughts may (or may not) be right. It doesn’t mean that you accept that they ARE right. It just means that you accept the not knowing.

As long as you continue living with the hope that you will have certainty about the past, the future, and the kind of person you are, OCD will continue to have a grip on you. Yes, the thoughts about what you did and what kind of an immoral human being you may be are horrific. But these are thoughts. Not facts. Hold them lightly. All our thoughts may or may not be true. As long as we don’t take them too seriously, we have the freedom to live our life. Allow the uncertainty to be there and continue with your day.

9.     Seek treatment. Your OCD will, of course, tell you that treatment will not help, that you will be judged, that going to therapy is just an excuse to avoid repenting, that nobody can possibly understand what you are going through, that the shame will be unbearable, that  your OCD is very different from other OCDs and that, of course, it may not even be a real OCD. Just like with the other thoughts, hold these thoughts lightly and don’t allow them to sway you from getting your life back.

10.     Make sure that your therapist specializes in OCD and practices ERP (Exposure and Response Prevention) and ACT (Acceptance and Commitment Therapy). This is crucial. Seeing somebody whose method of treatment is CBT but who doesn’t mention ERP as their treatment approach on their website or in your phone conversation is not enough. Not all CBT is applicable for OCD and the therapist needs to know a very special way of using CBT for the treatment of OCD.

If your therapist is not an OCD expert, he or she may just unwittingly co-compulse with you by providing reassurance, engaging in figuring things out, examining your thoughts, teaching you strategies to get rid of the thoughts or arguing with the thoughts, etc. If you read this article up to this point, you know that all of those are compulsions and that the relief from them is very short-lived.

OCD is a treatable disorder. There is so much that you can do to get your life back. Don’t delay living your life and don’t lose hope.

Think you may have a real event OCD? Share your story in the comments below!

If you enjoyed this article, follow us on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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People tend to think about OCD as a washing, organizing, and checking disorder, the reason being is that OCD is presented this way in the media. But there are numerous other manifestations of OCD that are very common but may not be immediately visible to others. 

Some Less-Known, but Very Common, OCD Fears 

Fear of Offending God, Doing Religious Rituals in a Wrong Way, or Being a Bad, Immoral, or Unethical Person (Scrupulosity)

This usually looks like the OCD sufferer is just a devoted, spiritual, or highly conscientious person. But it has more to do with OCD than religion or morality.

This type of OCD may lead to numerous, extremely rigid religious rules that greatly exceed what the person’s religion prescribes.

A person may question himself whether he is really concentrating during a prayer, if his faith in God is strong enough, or whether he accidentally mixed up the words of a prayer. This leads to repeating the prayer over and over again - sometimes for hours at a time. 

Sometimes a person may start avoiding the place of worship as he feel unworthy of being there, or because his intrusive thoughts may increase when he attends the service.

Moral scrupulosity includes worrying about being a bad person, being a racist or an anti-Semitic, inadvertently telling a lie or keeping a secret, acting unethically or selfishly.

Rituals may include excessive confessing, self-reassurance, performing altruistic acts with the goal of proving that he is a good person, and mentally reviewing his behavior – trying to figure out if he has accidentally sinned or behaved immorally.  

Unfortunately, very few religious leaders are aware of OCD. When a scrupulosity OCD sufferer comes to them for advice, they often encourage him or her to pray or confess more (that is, further reinforcing the compulsive behavior). 

Excessive Worrying About Health (Illness Anxiety, Health Anxiety, Hypochondria)

This is an obsessive preoccupation with having a serious physical or mental disorder in spite of normal medical exams, test results, and reassurance by doctors. In addition to worrying about having an illness, the sufferers often worry about being responsible for missing the early signs of the disease and living with the consequences of not having done enough to obtain the correct diagnosis and treatment.

This fear leads to constant checking of the perceived symptoms, visiting medical professionals, repetitively seeking reassurance, asking family members to have a look at any visible symptoms, obsessively Googling, and requesting unnecessary tests.

Of course, just like with any other OCD, no amount of reassurance or negative test results provides long-lasting relief. The person suffering from this type of OCD feels better for a little while after being reassured by a medical specialist, but then starts worrying that the doctor or the lab may have missed an important sign of the illness or mixed up the results -- and the anxiety starts again.

Scary Intrusive Thoughts About Causing Harm to Oneself or Others

These include fear of physically attacking another person, hurting or molesting a child, shouting a racial slur in public, swerving the car into traffic or off a ramp, pushing a person under an approaching subway train, stepping in front of oncoming traffic, harming a baby, etc. The fears can also be related to the person not being sure if he or she had already committed some horrible act or crime, which leads to excessive physical and mental checking.

Sometimes, the sufferer may be afraid that he or she may cause harm to others just by thinking certain thoughts, having certain images, or performing (or failing to perform) certain action.

Understandably, having these unwanted thoughts causes a great deal of shame and embarrassment. It also leads to numerous compulsions, such as mentally reviewing past thoughts and behaviours, confessing, trying to “neutralize” or disprove disturbing thoughts, and avoiding people, objects, and situations that are related to these thoughts.

Fear of Having Caused a Hit-and-Run Accident

This relates to the previous category of fear of causing harm, but it’s so prevalent that it deserves a separate category. A person with OCD may question herself wondering if maybe she was too distracted and accidentally harmed a pedestrian when driving. Any bump on the road or a noise in the car is interpreted as hitting a pedestrian.

It is not unusual for a person with this type of OCD to consistently make U-turns to go back to check the driving route or listen to the radio and check the news to make sure there was no hit-and-run accident on their route. This checking is a compulsion that is aimed to relieve the anxiety caused by the thought of potentially having caused a car accident. 

Fear of Being Gay (HOCD, Homosexual OCD, Sexual Orientation OCD)

HOCD is a fear of being gay (or, if the sufferer is gay, then sexual orientation OCD is the fear of being straight). This includes worries about being a fraud, a liar, the fear of never being able to have a healthy relationship, or of living in denial of who the person really is.

Common compulsions include trying to figure out their sexual orientation once and for all with 100% certainty. The sufferer may look at pictures of same-sex people while trying to make sure that he or she isn’t attracted to them, ruminate about past experiences trying to figure out if he or she ever had romantic feelings for a same-sex friend, check for a groinal response, try to neutralize the thoughts, and ask for reassurance about being straight. 

Emotional Contamination Fear (Mental Contamination)

Like being afraid of becoming contaminated by germs in the most well-known OCD type, here a person is afraid of being “morally contaminated” by coming into contact with a “bad” person or a specific item (say, touching am image of a pink ribbon may contaminate them with cancer; encountering a homeless person or a person with piercings or tattoos may contaminate them with “badness”). Similar to germ contamination, this type of mental contamination also seems to spread to other people, objects, thoughts, quotes, pictures and anything else that could be even very remotely associated with the original “mental contaminant.”

The main compulsion is usually to avoid all proximal and distal stimuli. Additionally, the person with OCD often develops numerous visible and mental rituals to try to prevent and “un-do” the contamination. 

Responsibility OCD

This type of OCD is usually known as “checking OCD” and is related to the fear of being responsible for some calamity that may occur or already occurred.

It often manifests as checking if the door is locked or if the electric appliances are turned off. Other manifestations include checking food and beverage containers for possible damage, checking emails and tests repeatedly before (and after) sending them, mentally reviewing all the previous checking, and, of course, seeking reassurance.

Interestingly, it is not necessarily the disaster itself that some sufferers fear the most. Sometimes, it takes a person hours to leave the house as she keeps re-checking everything. But she is perfectly fine when her husband is the last one to leave the house even though she knows that he will not do the checking.

Or, a mom would spend hours checking and decontaminating the food before cooking for her kids but will let the kids eat the non-decontaminated food that their dad cooked as long as the mom wasn’t present during that cooking time. This is why I’m referring to this OCD type as responsibility-related. These individuals can’t tolerate the thought of being responsible for causing a disaster.

Relationship OCD (ROCD) 

Relationship OCD involves difficulty tolerating uncertainty about the person’s romantic relationship. The person with OCD keeps wondering it her partner is the right one, or whether she has made the right choice, or if she loves her partner enough. It is difficult for a person with this OCD type to tolerate even the slightest doubt about her choice of partner.

Common compulsions here are monitoring the feelings and trying to figure out if these feelings are real, comparing her partner unfavorably to other people, mentally reviewing everything about the relationship, and repeatedly asking friends and family what they think (seeking reassurance).

Existential or Philosophical OCD

Existential OCD includes endless, intrusive, repetitive, and very disturbing thoughts about the meaning and reality of life. These questions have no true answer. Typical obsessions include questions such as:

• What is the meaning of life?

• What is life is just meaningless?

• Why am I here?

• What is the point of it all as we will all die in the end?

• How can I continue living if I am unable to find the real meaning of life?

• Is the world around me real?

• What if everything is staged, like in the Truman Show?

• Am I real or is somebody manipulating my brain?

The main compulsion is usually trying to figure it all out. Other compulsions include trying to disprove the thought, engaging in philosophical discussions, reading philosophical literature trying to find answers, seeking reassurance, researching the meaning of life, trying to distract oneself, or trying to stop the thoughts. As with the other OCD types, most compulsions are aimed at finding clarity and certainty.

Hyperawareness (Sensorimotor) OCD

This type of OCD is not well-known and is usually missed or misdiagnosed.

This is an obsession with not being able to stop thinking about a body part or a body function such as blinking, swallowing, breathing, or even thinking. The sufferer concentrates on these body parts or automatic processes and worries that he or she will not stop thinking about them, will go crazy, will never be able to live a normal life, etc. 

This leads to compulsions of monitoring, reviewing, or checking the thinking about breathing, blinking, or another body process, body part, or a body part’s position. Other compulsions include trying to figure it out, trying to distract oneself from thinking, trying to stop the thinking, avoidance of any triggering situations or words, and seeking reassurance.  

Patterns Common to All OCD Sufferers 

As you can see, there is much more to OCD than organization and fearing germs. The possibilities of OCD obsessions are endless. It is not the obsession content that determines whether or not a person has OCD -- it’s the process of how the person relates to his or her intrusive thoughts.

When a person with OCD has an obsession, he or she feels compelled to do something to decrease the discomfort caused by the thought. This is driven by the mistaken belief that it is possible to somehow control the internal experiences (emotions, thoughts, images, urges, or memories). This includes asking for reassurance, checking, trying to figure things out, seeking absolute certainty, attempting to get rid of the thoughts or feelings (the internal triggers) or to neutralize them, avoiding specific situations and people (the external triggers), and seeking distractions from distressing thoughts, feelings, or images.

This usually brings some temporary relief, but OCD always comes back for more and the cycle of obsessions and compulsions continues and becomes stronger and more time-consuming.

OCD usually attacks things that matter the most to the person; therefore, the obsessions cause a great deal of distress.

In addition to the process of becoming hooked by intrusive thoughts people with OCD usually have the following characteristics:

1.    Most OCD sufferers have an overwhelming need to be certain and feel that they are unable to function until they reach that point of 100 percent certainty. But, of course, this is impossible in our unpredictable life and, therefore, the endless “What if?” questions continue. OCD is sometimes called a doubting disorder and it’s a pretty accurate description.

The endless quest for certainty leads to constant “problem-solving” that gets in the way of the person’s ability to just live their life.

You can read more about the need for certainty here.

2.    Another common characteristic of people with OCD is feeling unable to tolerate the possibility of being responsible for a potentially wrong or harmful action.

OCD Treatment

The approach to the treatment of OCD seems counterintuitive at first glance.  Instead of trying to get rid of the obsessions (which, of course, would be highly desirable, but unfortunately, is impossible), the treatment includes stopping the rituals. This is called Exposure with Response Prevention (ERP, ExRP) and involves giving the person tools to not let OCD push them around. ERP is a very specific component of Cognitive Behavioural Therapy (CBT).

ERP is a very active therapeutic approach that allows people to practice voluntarily putting themselves in a situation that triggers compulsions and still not compulse. Gradually, this becomes easier to do.

The treatment is especially effective when combined with Acceptance and Commitment Therapy (ACT). 

If the treatment is successful, the person may still have some obsessions, but does not engage with them and is able to just carry on with what he or she was doing.

Think you or someone you know may have OCD? Leave a comments below and share with us!

If you enjoyed this article, follow us on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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If you are a parent of a child who has Obsessive Compulsive Disorder (OCD), you know too well how easy it is to get entangled in an endless argument where you try to use logic to no avail. You tell your child how unlikely it is that something bad will happen, you teach her to think positively, you reassure her, and you try to help her out.

You may be doing those things since you believe that they will help your child overcome anxiety. The child finally calms down and both of you can continue with your day. Unfortunately, the anxiety reduction is short-lived, and soon after the ritual is performed or you managed to reassure your child, a new wave of obsessions and doubt begins. While desperately trying to help your child, you may inadvertently help OCD tighten its grip over her.

Don'ts

1.    Use logic and reasoning. What? But isn’t that how we teach our children about the world? Yes. But in this case, it’s not the child you are trying to reason with – it’s OCD, a little glitch in the brain. Do you really want to dignify it by having a discussion with it? Also, arguing with OCD is like arguing with a toddler - it will always out-argue you.

2.    Reassure your child by telling him not to worry, that everything is going to be OK, that everybody is safe, and that bad things will not happen. It feels good to be able to ease the child's distress, but the relief will not last long. The OCD will always come back for more until your child learns to stand up to it. 

3.    Accommodate by rescuing the child with scrubbing the floors or the bathroom, doing extra loads of laundry, arranging objects in a certain order – until they are “just right,” checking that the doors are locked, and avoiding “bad” numbers in the house. You are trying to be helpful, but accommodating OCD just reinforces its symptoms.

4.    Tell your kid to just stop the nonsense. The child didn't invent it. As difficult as it is to believe, it's OCD that is whispering (or screaming) those things in her ear. Therefore, it's our job to help the child teach OCD to stop its nonsense. Blaming the child, who is the victim in this situation, is unfair and is not going to help. 

5.    Punish. Your child doesn’t want to be doing any of the compulsions, and he REALLY can’t help it, as difficult as it is to imagine.

Want to find out more Don'ts? Check out this reminder of what not to do. 

Do's

1.    Explain to the child that as weird, embarrassing, and abnormal as those thoughts and ritual may seem to her, they are just a part of regular OCD stuff.

2.    Educate the child about the fact that anybody can have silly, bizarre, or scary thoughts. It’s just that people with OCD give those insignificant thoughts too much importance. They take them way too seriously. When they re-label those thoughts as “junk,” the thoughts quickly lose their power.

3.    Teach the child to separate himself from the OCD. Give the OCD a funny and/or derogatory name and call it by its name whenever it tries to bully your child. Some of my recent favorites: Plankton (not the tiny water organisms, but the annoying SpongeBob SquarePants character) and Cruella de Vil. Or just call it “OCD.”

“OCD wants you to wash your hands again.” “OCD is telling you to stay away from the knives.” Only speak about the OCD in the third person.

4.    Learn to separate the process and the content of OCD. It is not really important which arguments the OCD uses to get the child to perform a compulsion. It’s very important, though, to point out to the child that it’s the OCD – the glitch/ the bully/ the brain bug/ the silly hiccup/ Mr. Clean - that is speaking up now. Therefore, address the process by pointing out the offender (the OCD) and not the content of the obsessions. Tell your child, “The OCD is trying to trick you again.” Or ask, “Is 'the meanie dude' trying to bully you?”

5.    Explain to your child that by doing what the OCD requires of him, he just makes it stronger.

6.    Encourage the child to gradually postpone, or change the rituals. Or better yet, drop them altogether and see what happens. Ask, “Did what you expect happen?” or, “Was it as bad as you expected?”

7.    Explain to your child that the anxiety will pass even if she does not perform any rituals.

8.    Watch out for new rituals. Remember Lernaean Hydra from Greek mythology? The one that Heracles was sent to slay? For every head chopped off, the Hydra would regrow two heads. I often liken OCD to the Hydra, as when the child is finally able to overcome one ritual, the OCD will try to sneak up on her and replace it with another obsession or ritual. It’s very important, therefore, to stop OCD early on when a new ritual emerges.

9.    Look carefully for any small victories of your child has over OCD. Remember, standing up to a bully is very scary. If your child was able to delay a ritual or to change it even a little bit – praise, praise, praise! This is how you encourage your child’s new behavior of standing up to OCD.

10.  Get informed. Read up on OCD. There is a lot of information online, and there are great books on OCD. If you are searching for a therapist, make sure you find an OCD expert and not a generalist.

This advice is not a substitute for therapy. OCD is a complex disorder. Most people with OCD (children and adults) will require therapy to learn to manage their OCD. This therapy is very different from other forms of talk therapy and involves Exposure and Response Prevention (ERP). The therapy is especially effective when combined with Acceptance and Commitment Therapy (ACT). It teaches kids to face their fears and to boss back their OCD.

As a parent, you have a very important role in this process - supporting your child and helping her do what children naturally do best – REBEL. Yes, rebel against a pesky brain glitch that is trying to boss her around!

Would you like more ideas and resources for helping your child rebel:

• Print out our handout for ideas for Rebelling against OCD.

• If you would like to learn more about anxiety, how it operates, and how to cope with it, please read our blog about anxiety and tips and tricks for managing it here.

• If you are wondering whether you or your child has OCD, check out this article: Do I have OCD? Sorting out Through OCD Confusion.

• Get more information about our OCD Clinic.

Have you been unwittingly engaging in dome don’ts? Have you tried some do’s? How did it go? Share what worked and what hasn’t in the comments below!

If you enjoyed this article, follow us on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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Do you wonder whether you may suffer from undiagnosed OCD?

You may have intrusive thoughts and may even perform some rituals; but your room is unbelievably messy, and you don’t feel the need to wash your hands all the time. Can you have OCD and be messy?

Even though your thoughts are driving you nuts, they are actually about realistically dangerous things, ones that most people would be scared of. Plus, nobody even notices your rituals.

And yet, you find yourself being consumed by those thoughts.  As if that's not bad enough, the thoughts are so embarrassing that you prefer to suffer alone than tell anybody about them.

Given the relatively high prevalence of OCD (about 2.3% lifetime prevalence), it is unfortunate that this disorder is still largely misunderstood. This confusion seems to be one of the factors that lead to people with OCD not being properly diagnosed and not seeking treatment. 

Here are some of the main factors that contribute to the confusion about this common, yet mysterious disorder.

OCD Misconceptions

1. The difference between the everyday use of the word “obsessed” and its meaning in the context of the disorder.

We all know what someone means when they say they are depressed, even though that person may be simply feeling sad. But, it’s nothing like that with the word “obsession.” When we say we are obsessed with our new friend, or a podcast, or our new shoes, we mean that we can’t get enough of that; we love it, and derive great pleasure from thinking about, listening to, wearing, or otherwise indulging in our “obsession.”

This feeling could not be more different for a person who experiences obsessions as part of their OCD. Those (true) obsessions are totally unwanted and disturbing intrusive thoughts, images, or urges. The key word here is unwanted. Far from being pleasurable, those thoughts or images cause OCD sufferers great distress, anxiety, disgust, or even shame.

As you can see, our everyday use of the word “obsession” is actually the opposite of what people with OCD experience.

2. The persistent, stereotypical image depicting people with OCD as clean freaks or neat freaks.

This is a tricky distinction as people suffering from OCD do often engage in excessive cleaning or organizing. However, not all people who wash or clean excessively suffer from OCD, and not all people with OCD feel the urge to clean (as explained in the next section).

Let’s say your friends tease you about “being so OCD” with some habits. How do you know whether you may really have OCD?

To answer this question, think about the reasons you wash or clean, and how you feel after you are done washing or cleaning. If you take great pride in being a neat and organized person, feel a sense of accomplishment after you are done, and secretly suspect (or openly declare) that others are just clueless in matters of personal hygiene and housekeeping, chances are you do not suffer from OCD.

If, on the other hand, your urge to clean is a response to a strong feeling of fear, distress, or disgust and you feel that you just have to do it – otherwise you won’t be able to go on with your day - then it may be a sign of OCD.

It is, of course, important to get properly diagnosed by a psychologist or a medical doctor to know for sure.

So, we established that being an overzealous organizer, washer, or cleaner by itself does not mean that you have OCD. But, can a person have OCD if they are messy or if they don’t care much about being clean?

3.    The idea that a messy person can’t have OCD.

As discussed above, a common misconception is that a person with OCD is a super-organized, perfectionistic clean freak who is preoccupied with making sure that everything is sterile and in place. People tend to believe that messiness and OCD don’t go together.

This is a misunderstanding I witness quite frequently in family members of a newly diagnosed OCD sufferer. A typical dialogue may look like this:

Me: Your son’s symptoms are consistent with Obsessive Compulsive Disorder – OCD.

Patient’s mom: This just can’t be! You gotta see his room! And I have to make him shower, otherwise he won’t!

The fact is the diagnosis of OCD has nothing to do with cleanliness, per se. Even though a fear of contamination is a common obsession in OCD, there are other obsessions that include:

-       Fear of harming self or others, or being responsible for causing a horrible event or making a dreadful mistake.

-       Unwanted sexual thoughts - often about changing sexual orientation or fear of being a paedophile.

-       Scrupulosity or religious and moral obsessions – fear of religious blasphemy, offending God, being an immoral sinner, or otherwise being an unscrupulous evil person.

-       “Just Right” obsessions, and awareness of an object or behaviour that is not symmetrical, not “right” or not “correct”.

-       Sensorimotor or hyper-awareness obsessions – fear of being unable to stop attending to blinking, swallowing, breathing, body positioning, physical sensations, memories, or thoughts.

Basically, OCD “attacks” anything and everything that may be of high value to a person, such as their morality, religious beliefs, their loved ones, their health, and even their relationships (this is also a common obsession – fear of the relationship being a “wrong one,” or falling apart).

You may have one (or more) type of obsession, but not have the others. That means that you may be preoccupied with doubts whether you may be gay, or whether you are likely to accidentally stab a family member with a knife, or if you were involved in a hit-and-run accident and drove away without noticing – and yet have absolutely no concerns about cleanliness.

4.    The fact that many of the thoughts that OCD sufferers experience as obsessions are the same as occasional thoughts that people without OCD may have.

Examples of such intrusive thoughts are:

-       What if I drop my newborn baby down the stairs?

-       I must always tell everything to my mother. If I don’t, that means I must be an immoral person.

-       If I come close to the railing of the balcony, I may jump.

-       I just admired a picture of a same-sex person; therefore, I might be gay.

-       What If I swerve the steering wheel onto the oncoming traffic?

We may all have those thoughts on occasion. Usually, they will be related to the things or people we value and cherish the most.

So what is the difference between people with and without OCD in regard to those thoughts?

It’s pretty simple. If a person without OCD experiences a thought like that, they will probably shrug, think, “Well, that was a weird one,” and forget about the thought pretty quickly.

When a person with OCD has a thought, they will likely become very concerned, wondering why on earth they would have a thought like that. They’ll think, “Oh no! What does that mean? Does it mean that I may harm my baby? This is very dangerous! I should probably not be left alone with the baby as it is not safe.” They may then put precautions in place to prevent the catastrophe from happening, such as avoid being left alone with the baby or stay away from the stairs. They may try to neutralize the thought by thinking a “good” thought. Or, they may engage in all kinds of rituals that calm them down and prevent anything bad from happening.

The bottom line is that it is not the content of the thought that distinguishes between people with and without OCD. The thoughts are the same, even though some of them may be pretty quirky.  It’s the interpretation you give the thought that matters. If you are able to shrug an intrusive thought off (maybe even thinking – wow, even a good person like me can have a weird thought like that), then you do not have OCD.

If, on the other hand, those thoughts cause you extreme anxiety and you start engaging with the thoughts and take various precautions which takes a great deal of your time and energy – you may have OCD.

5.    To make matters even more complicated, some of the compulsions can be seen as regular everyday behaviours.

Compulsions are behaviours or thoughts that people with OCD use to reduce their distress. Any common daily behaviours, such as washing, praying, dressing, driving, apologizing, drinking water, counting – anything at all can be compulsions. Or not.

So how do you know?

If those behaviours are part of your daily routine and you feel productive, or at least neutral doing them – those are probably not compulsions.

If, however, you are doing them in order to find relief from your distress or anxiety, you’d much prefer not to do them, and they take a great deal of time – those are likely compulsions.

But what if you experience unwanted intrusive thoughts, which cause you enormous distress, but you don’t have any behaviours to reduce the distress? You don’t clean, wash, knock, tap, check, or repeat. Does it mean it’s not OCD?

6.    If a person does not have any rituals, they don’t have OCD.

This is actually a very common misconception even among doctors and mental health professionals. The absence of visible rituals does not mean the person does not have OCD. Often, people may have frequent intrusive disturbing thoughts that cause anxiety and they cope with their distress by “invisible means,” such as:

-       Avoiding places, objects or situations that may lead to distress. You may avoid children if your obsessive fear is being a paedophile. Or, avoiding pictures of attractive same-sex models if you are afraid you may be gay. You can avoid knives (so you don’t stab), heights (so you don’t jump), being alone with kids (so you don’t harm them), etc.

-       Mental review – trying to gain certainty about things, going back in memory checking to make sure no harm was caused.

-       Reassurance seeking – asking for people’s opinions, or surfing the Internet trying to figure out whether the fears are justified.  

-       Praying.

-       Counting.

-       Thinking a positive thought in order to “neutralize” or “cancel out” a bad thought.

Here, it is important to mention another common misconception:

7.    The Pure-O myth.

This term is popular over the Internet and is sometimes used to describe individuals with OCD that do not have compulsions. In some way, this is the opposite of #6.

It is true that theoretically it is possible to have just obsessions and no compulsions and still be diagnosed with OCD. According to the DSM-5, the diagnosis requires the presence of either obsessions, compulsions, or both.

I have to say, though, that I have yet to see a person that has absolutely no compulsions whatsoever. Usually, after a closer investigation, numerous subtle hidden mental rituals come to surface.

8.    If a person with OCD can be convinced that those rituals are just silly, he or she will stop doing them.

This misconception can, of course, only be held by a person who never experienced the agony, horror, unbearable anxiety, never-ending distress, and shame that people with OCD struggle with daily.

Most people with OCD recognize that the rituals (visible or mental) do not make much sense. They would like nothing more than to become free from being consumed by those compulsions. Telling them to just stop is not going to work. They need a specialized treatment program called Exposure and Response Prevention (ERP) that is administered by a skilled professional. ERP is even more effective when combined with Acceptance and Commitment Therapy (ACT).

If you think that you (or somebody you know) may have OCD, it is important to get properly diagnosed by a professional. Please do not allow the above misconceptions stand in your way. Also, please don’t let the shame or embarrassment stop you from seeking help.

Have you heard any of these myths? Have they made uncovering the OCD diagnosis more difficult? Share your story in the comments below!

If you are a parent of child suffering from OCD, please read our blog Don’t Argue With a Brain Glitch. (10 Do's and 5 Don'ts for Parents of Kids with OCD).

If you enjoyed this article, follow us on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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If you have OCD, you have probably read numerous blog posts and books about the treatment strategies for OCD. Maybe you even went to therapy.

It is very likely that in the process of seeking OCD treatment you have become disillusioned as the suggested strategies haven’t worked for you. This may have happened even if you went to see a therapist that practices using the Cognitive Behavioural Therapy (CBT) framework.

When patients call us to inquire about our services, they often say that they tried CBT and it hasn’t been useful to them at all. Moreover, some feel that it created even more obsessions and compulsions and their psychological state worsened.

CBT is the recommended evidence-based approach to the treatment of OCD. How come, then, it hasn’t been helpful to all these people?

The problem is that not all CBT techniques work for OCD. They may work for mild to moderate anxiety, but OCD requires a very specialized approach. It is called Exposure and Response Prevention (ERP or ExRP). This approach is strongly rooted in CBT, but it is an approach by itself nevertheless, and CBT techniques are used in a different way within ERP.

Moreover, even ERP has changed in recent years. If you have tried Exposure therapy in the past, you may be surprised reading the following list of the strategies that we do not use as your exposure therapist may have encouraged you to use them in the past.

One example of exposure therapy done “the old way” is Systematic Desensitization. This is an older behavioural intervention that some therapists are still using to address compulsions. It includes very gradual exposure to OCD triggers and is combined with relaxation techniques that are used to control anxiety. The goal is to lower anxiety and to approach the feared trigger in a relaxed state. As you have probably figured out on your own the hard way, the attempts to reduce anxiety may successfully diminish it for a short period, but it always comes back. Also, this technique implies that you can only do exposure (that is, face your fears) when you are relatively calm, which is not true: you can be very anxious and face your fears anyway.

Another example is concentrating on rating anxiety and aiming to reduce it during the exposure. This usually includes rating and re-rating your SUDs (Subjective Units of Distress) and gearing the exposure toward reducing them in half. Similar to the previous example, again the focus here is on anxiety reduction, which in itself creates struggle and unnecessary suffering.

Here are 9 things that you might have done in OCD therapy before that are mostly ineffective for OCD treatment:

1.    Exploring Childhood and Teen Issues that Might have Caused OCD

It may be tempting to both the therapist and the patient to try and uncover the “real root of OCD” through lengthy discussions, then focus on attachment and childhood relationships and experiences. It seems that if you finally figure out what the initial OCD cause was, then the problem will be resolved.

This quest for uncovering childhood experiences is further reinforced by the fact that in many cases, OCD does seem to be triggered by a certain experience.

Some case examples:

When Dan was nine years old, he was hospitalized with salmonellosis. At discharge, his doctor urged him to wash his hands really well to avoid getting bacterial poisoning in the future. This was the start of his compulsive washing that worsened throughout the years.

Helen remembers a pastor at her church talking about bad people going to hell. She came home that day and recited extra prayers. After that she felt the urge to ask her parents repeatedly if she was a good girl and ask for forgiveness just in case she wasn’t. The praying and asking for forgiveness gradually became excessive and time-consuming.

25-years-old Angela was a big supporter of the #MeToo movement. She read and shared women’s stories on social media. One day, while reading another story, she had a thought about how horrible it would be to be a sexual predator. Since that day, she makes sure to stay away from other people in the subway and in other crowded places. She spends a lot of time reviewing her days and trying to be certain she did not cause inappropriate sexual contact. She now tries to never go out alone so that she has somebody else with her (a “witness”) to reassure her that she didn’t touch another person on the street.

The issue with the cases above is that these experiences did not cause OCD. They may have influenced the content of the person’s obsessions, but the predisposition to sticky intrusive thoughts most likely existed prior to these occurrences.

Finding the cause rarely has a significant impact on the treatment. Some people spend years doing “deep therapy” but they rarely find the “root,” and even if they do, the treatment is still the same.

You may never know what “caused” or triggered your OCD. The good news is that you can still get effective treatment and significantly improve your life.

Be very careful if your therapy involves searching for the origin of your OCD. It is much easier to engage in this kind of therapy than to do exposures that can be unpleasant. But then the therapy becomes just another avoidance behaviour where you invest effort and energy in not facing the real problem.

2.    Examining the Evidence that Supports or Disproves the Thoughts

This is a legitimate CBT technique called Automatic Thoughts Record. You write down all the evidence that supports the thought, then you write down all the evidence that doesn’t support it and after that, you come up with a more balanced, realistic thought that is supposed to reduce your distress.

But it doesn’t reduce your distress. Not in the long term. The reason for that is that your OCD doesn’t concentrate on logic or reality. It zooms in on a possibility. And anything is, of course, possible. OCD then makes this tiny possibility look like a huge probability.

Thought records don’t work for OCD because when you are anxious, you concentrate not on how unlikely something is to happen, but on how horrible it will be if it happens.

To make matters worse, this technique often leads to an increase of two very common compulsions -- the “figuring it out” compulsion and the reassurance-seeking compulsion. So, definitely a no-go for OCD treatment – you have enough compulsions, why create more?

3.    Working on Stopping the Obsessions

This is, of course, what every person with OCD wants – to stop the obsessions from entering their mind. If it was possible, that would be amazing! Unfortunately, there is no way to keep the thoughts from being generated by your brain. The only things that you can stop are engaging with these thoughts and performing the compulsions.

Still, there is a lot of misinformation out there about strategies for thought-stopping, such as rubber band snapping, screaming “Stop!” when you have an intrusive thought, replacing a “bad” thought with a “good” one, using distractions, or reciting positive affirmations.

Some people with OCD actually have a compulsion of suppressing their thoughts (one of my clients calls it a “self-induced amnesia”). Again, the last thing we want to do in treatment is to create more compulsions.

Alas, these thought-stopping strategies are like a Chinese finger trap – the one where you stick your finger in and then try to pull it out. The harder you pull, the more your finger becomes stuck. Similarly, the more you try to get rid of your thoughts, the more importance you give them and the “stickier” they become.

4.    Working on Anxiety Reduction

This one sounds so good. And you hear about it everywhere. There are endless resources on the internet for anxiety reduction and numerous books are devoted to that too.

The problem is, attempts to get rid of anxiety lead to placing even greater significance on the anxiety. When you are trying hard to be anxiety-free, you reinforce the belief that anxiety is dangerous and intolerable. This, in turn, feeds the anxiety. The less we are willing to experience anxiety, the higher the anxiety will be. Just like trying to stop the obsessions makes the obsessions stronger, trying to get rid of anxiety increases it. What we resist, persists.

Anxiety is a natural response to a perceived threat, and we can’t override it by learning some quick tricks.  We can’t really fool our sympathetic nervous system that evolved to keep us safe from real dangers. But what we can do is learn not to let anxiety control our lives.

When we allow ourselves to experience anxiety, fear, disgust, discomfort, or distress without performing the compulsions, we give ourselves an opportunity to discover that these emotions may be unpleasant, but they are not intolerable. As a good side effect to doing this, anxiety does diminish more often than not, but this cannot be the goal of our treatment -- otherwise it will backfire.

You can read more about how anxiety operates here: https://www.turningpointpsychology.ca/blog/how-anxiety-and-fear-work

5.    Breathing, Meditation, Relaxation, and Positive Thinking

These techniques are closely related to anxiety reduction, but I decided to outline them separately as they are very prevalent in treatment. These techniques sound very legitimate and healthy. And they are, on one condition: they should not be used as “safety behaviours” for anxiety reduction.

So if you want to start or end your day with these practices – more power to you. You may feel more grounded and experience more calmness and clarity throughout the day.

But practice those as a response to your obsessions – and very quickly they turn into compulsions and reinforce your OCD. Therefore, we do not incorporate these strategies into our OCD treatment.

One exception is mindfulness meditation. This is a very specific type of meditation that does not involve relaxation. Its goal is to allow the thoughts and images to come and go without engaging with them or trying to get rid of them.

6.    Receiving Supportive Reassurance

“Well, isn’t this what the therapist is for?” you may ask, -- “To support? To kindly reassure?” There is even a term – supportive counselling, which many therapists use when describing their therapeutic approach.

Bad news: No, OCD treatment cannot be described as supportive counselling.

More bad news: Reassurance is one of the most common compulsions in all OCD types. If the therapist is constantly reassuring you with the purpose of making you feel better, it means that he or she is co-compulsing with you. It will make you feel better during the session. And, it also will make your OCD stronger in the long run.

Good news: You don’t need reassurance to overcome your OCD. In therapy, you will learn to be self-compassionate and to support yourself in this difficult battle with OCD, while taking a very active approach to rebelling against it.

More good news: The therapist will be supportive without resorting to reassurance. He or she will also teach you how to support yourself in this difficult process of rebelling against OCD and how to do it without seeking reassurance or engaging in self-reassurance.

To start addressing your reassurance-seeking right away, you can print out these reassurance coupons and limit yourself to 8 coupons per week. Please read the instructions for using the coupons here.

7.    Creating Numerous Exposure Hierarchies

An exposure hierarchy is a list of anxiety-triggering situations that are arranged in order of severity so that you can start facing these situations without resorting to compulsions.   

You and your therapist may create a few informal hierarchies initially just to get the idea of how exposure works. But for many OCD sufferers, who have a massive variety of obsessions and compulsions, numerous hierarchies just become overwhelming.

To make matters worse, it is very common for obsessions and compulsions to change, so creating hierarchies feels like playing a never-ending whack-a-mole game (you can read more about it here).

In a traditional ERP approach, exposure exercises are structured in such a way that you start from the items on the list that make you just a little bit anxious and gradually progress to more difficult items.  But, new research indicates that the best way to do exposure is to address the items on the list that vary in their degree of difficulty – in no specific order. Our clinical experience is consistent with that, so you will be encouraged to practice various exposures without concentrating too much on structuring them according to the level of difficulty.

In general, exposure hierarchy is a very helpful technique and if you are trying to cope with your OCD on your own, this is a great place to start. It’s just important to keep in mind that, especially in the case of numerous compulsions, it becomes too time-consuming and less effective.

Instead, it is imperative to really change your relationship with anxiety, to consistently rebel against your compulsions, and to practice all kinds of focused exposure as frequently as possible.

8.    Rating Your Anxiety or Distress

What? But isn’t it a well-known CBT strategy?

Rating and re-rating your anxiety is just another way of focusing on it. Aren’t you giving it too much attention already? It’s like giving extra attention to a misbehaving child. Not worth it. The anxiety may be mild, moderate, or strong. The goal of the treatment is to help you make choices to take steps toward living a rich, full, and meaningful life regardless of the severity of anxiety.

9.    Aiming to Lower Your Anxiety During Exposure in Order to Habituate to the Fear-Inducing Trigger

This is related to rating the anxiety as described in #8 and general anxiety reduction described in #4. The rating of SUDs (Subjective Units of Distress) is often done with the goal of reducing the anxiety during the exposure. This is done to monitor whether a habituation – getting used to the threatening external or internal trigger – takes place. It’s like getting used to the cold water in a swimming pool. After a few minutes you get used to the cold. Similarly, we can habituate to things we fear.

As stated at the beginning of this article, while exposure used to focus on anxiety reduction in the past, we now know that it is not necessary

The new emerging research shows that there are other mechanisms, not just habituation  that underlie the effectiveness of exposure. One of the latest researches and treatment directions concentrates on creating a new neural pathway in your brain – the non-fearful pathway. To cultivate this new pathway, you need to practice your exposure in a variety of situations and under a variety of conditions. The conditions may include practicing exposure in different places, different situations, with different people, and in different moods.

The more you use your new neural pathway, the stronger it will become and the more likely you will be using this healthy pathway in difficult times.

So, if you practice ERP and your fear goes down – great. And if it doesn’t, but you still don’t do the rituals – even better! This is the situation where a lot of learning occurs. You learn that you can have a high level of fear and still not do the compulsion. Congratulations! Your new healthy neural pathway is becoming more established.

So, at our clinic, we won’t do the strategies above. What will we do instead? Click here to read about our iRebel approach to the treatment of OCD.

Have you been in therapy for OCD? Have you recognized some effective or ineffective strategies? Share your story in the comments below and help other OCD sufferers get the right treatment!

To learn more about anxiety and effective ways of dealing with it in the long-term, read our anxiety blog.

If you enjoyed this article, follow us on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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Confused about numerous anxiety disorders? This is not surprising because there is a great deal of overlap between them. There is also a lot of misinformation going around about what characterizes each disorder.

Sometimes, it is difficult even for a mental health professional to establish a differential diagnosis. Common diagnostic struggles include questions such as:

-       What is the difference between panic attacks and a panic disorder?

-       Is it a panic disorder or a phobia?

-       Is it illness anxiety or OCD?

-       Is it GAD or OCD?

-       Is it agoraphobia or a simple phobia?

Here is a summary of the most common anxiety disorders and their characteristics*:

Social Anxiety Disorder (Social Phobia)

This is the fear of social situations and, more specifically, of being negatively judged, evaluated, or rejected by others. The sufferers are afraid of being humiliated or embarrassed. The most frequent feared situations are public speaking, talking to unfamiliar people, performing in front of others, eating or drinking in public, or even urinating in a public washroom (a shy bladder syndrome). In more cases than not, social anxiety is generalized across various social situations.

 Socially anxious people are preoccupied with the fear that they will appear weird, stupid, boring, weak, crazy, or unlikable. They may also be worried that others will notice them sweating, blushing, shaking, staring, having an awkward body posture, or speaking too quickly or too slowly.

It is typical for socially anxious people to direct their attention internally during a social interaction. This is called self-focus. Social phobics become acutely aware of their internal sensations and emotions. Often, they also have distorted images of themselves looking and sounding awkward and weird and (mistakenly) perceive these as the evidence of how others see them. These images are based only on their self-perception, but they contribute to even more anxiety.

Another negative consequence of self-focus is that because the person’s attention is directed inwards, many important social cues get missed. This, of course, may objectively interfere with the natural, flexible flow of a social interaction.

Socially anxious people attempt to avoid the discomfort caused by social interactions by staying away from anxiety-provoking situations, and often become isolated.  

Panic Disorder

 Panic disorder is diagnosed when one has recurrent panic attacks and constantly worries about having another attack. The following symptoms frequently occur during the attacks: heart palpitations, sweating, shaking, nausea, feeling of choking, tingling, dizziness, shortness of breath, and fear of dying, losing control, going crazy, or some other imminent catastrophe happening.

The main feature of panic disorder is misinterpreting bodily sensations in a catastrophic way. That is, a person perceives a normal, harmless physical sensation as a sign of impending doom.

The disorder is maintained (and often made worse) by selective attention and monitoring of the physical symptoms, as well as by avoidance and safety behaviours. The purpose of these avoidance and safety behaviours is to try to prevent the feared catastrophe from occurring.

Generalized Anxiety Disorder (GAD)

Generalized anxiety disorder is characterized by excessive and seemingly uncontrollable anxiety and worry about a wide range of events or activities, while the person feels restless, fatigued, and irritable. The worry is so omnipresent in the person’s life that it affects daily functioning, as the person has difficulty concentrating, relaxing, and sleeping.

This disorder is characterized by having a “worry chain” – continuously jumping from one “what if?” to another. People with GAD sometimes even worry about not worrying! 

There are several patterns that are typical to people with GAD:

-       They perceive worry as dangerous and are concerned that it may lead to them becoming sick or will make them go crazy. So, not only do they just worry, they also worry about worrying. There is even a name for that – metaworry (a worry about worry).

-       In spite of the above, they also see worry as helpful. That is, they believe worry will help them prepare for the future and make informed decisions.

 -       Somewhat counterintuitively, people with GAD are not as good at vividly imagining the feared catastrophe as non-anxious people. It is theorized that the cognitive process of worry protects them from having disturbing images. That is, constant worrying is still less scary than actually imagining the unimaginable.

-       Another process which usually characterizes all GAD sufferers (and most other people with anxiety, but to a lesser extent) is the inability to tolerate uncertainty. As pretty much everything in life is uncertain, this quest for certainty, of course, backfires and the worry continues.

Specific Phobia

This is the fear of a specific object or situation such as animals, heights, thunderstorms, or seeing blood or needles. It is common for a phobic person to have more than one phobia.

People with phobias actively avoid their feared situations or objects. When they can’t avoid, their fear is intensified and may even lead to panic.

Phobias usually develop in childhood. Sometimes there is a traumatic event that precedes the development of a phobia. A person may also learn about the situation or object’s dangers from the media or from another person. In many cases though, there are no identifiable precursors to the development of the fear. 

 Similar to other anxiety disorders, phobias are maintained by selective attention to the environment, catastrophic predictions, and avoidance and safety behaviours.

Phobics tend to overestimate the probability and the extent of harm, while underestimating their ability to cope.

Agoraphobia

This is a fear or anxiety about being in either open or enclosed spaces, using public transportation, being in a crowd, standing in line, or being outside alone. Agoraphobia often accompanies panic disorder.  

Agoraphobia is very similar to a specific phobia. The main difference is that to be diagnosed with agoraphobia, a person must be fearful of at least two agoraphobic situations (say, travelling in a vehicle and being in enclosed spaces). If the fear is limited to only one agoraphobic situation, a diagnosis of specific phobia is made.

Obsessive Compulsive Disorder (OCD)

OCD is characterized by having obsessions and compulsions. Obsessions are recurrent, unwanted, intrusive thoughts, images, or urges that cause anxiety or distress.

Compulsions are behaviours or mental acts aimed at reducing the distress caused by obsessions. Compulsions may be visible or invisible to others (as in “Pure-O” OCD).

What happens with OCD is that a person has a normal, intrusive thought but perceives it as meaningful or dangerous. That is, it’s not the thoughts that drive this disorder; rather, it is giving the thought a lot of attention and trying to get rid of it or neutralize it that turns a thought into an obsession. The more the person engages in overt or mental compulsions, and, thus, the more significance they give to the thought, the “stickier” the thought becomes.

OCD sufferers tend to overestimate the probability of harm, have difficulty handling uncertainty, and often have an overly inflated sense of responsibility.

Some “Pure-O” OCD types, such as an OCD related to constantly questioning whether a person is in the “right” romantic relationship (ROCD), strongly resemble GAD. The constant worrying, engaging with the thoughts, and intolerance of even the slightest uncertainty are common to both disorders.

 The main distinctions are the presence of intrusive thoughts that are often exaggerated and even inappropriate, as well as the presence of rituals in the case of OCD. While the rituals are mental, they are still rituals (such as neutralizing, checking, asking for reassurance, trying to figure things out, etc.). In GAD, however, it is the excessiveness of worry that really characterizes the disorder. In some cases, it may be difficult to distinguish with certainty between the two disorders.

Illness Anxiety

This is the preoccupation with having or getting a serious disorder. It is accompanied by significant anxiety about health and numerous health-related habits such as checking, monitoring, reassurance seeking, or avoiding.

It is common to attend endless medical appointments and repeatedly request unnecessary medical tests. It doesn’t matter if the doctor agrees to the test requisition or not. In either case, it evokes even more anxiety. If the doctor refuses to provide a referral, it is interpreted as the doctor being dismissive and likely to overlook important symptoms. If the doctor succumbs to the pressure and refers, then the patient thinks that something serious must be going on with them for sure; otherwise the doctor wouldn’t have referred them. 

Repeated reassurance seeking usually affects not only the person with illness anxiety and their medical providers, but also their family members.

Spending hours checking the symptoms and Googling medical information interferes with the person’s daily functioning.  

The pattern of this disorder is similar to panic disorder. In both cases, the person catastrophically misinterprets a physical sensation. The main difference is that with a panic disorder the person expects the catastrophe to be imminent, while with illness anxiety the person fears having or acquiring a disease that will cause them suffering or death in the future.

It is also very similar to OCD with intrusive, scary thoughts about getting a disorder resembling the obsessions, and checking, avoidance, reassurance seeking, etc. being the compulsions. People with OCD usually have other obsessions and compulsions, but otherwise, the symptoms (and the treatment) of illness anxiety are pretty much the same as of OCD.

What is Common to all Anxiety Disorders

You may have noticed that many cognitive and behavioural patterns are similar across all the disorders.

In all the disorders described above, there is usually an internal or external trigger that sets off some catastrophic interpretations of it. This evokes anxiety, which, in turn, leads to even more scary thoughts or images. The person then feels very distressed and tries to engage in all kinds of safety behaviours to reduce the distress. They also go to great lengths to avoid the scary trigger the next time. These safety and avoidance behaviours make the trigger and the distress seem even more catastrophic and the cycle continues.  

Treatment of Anxiety Disorders

The treatment of all anxiety disorders involves radically changing the person’s relationship with their anxiety. Instead of building their life around the fruitless struggle to achieve certainty and reducing distress, the person is given tools to unhook from intrusive thoughts and to willingly accept the uncomfortable physical sensations, while making steps toward living a valuable, meaningful life.

The treatment starts with identifying the obstacles that stand in the person’s way of living the life they want (most likely those obstacles would include over-engagement with intrusive thoughts, as well as avoidance and safety behaviours). After that, through a combination of Cognitive Behavioural Therapy (CBT), Acceptance and Commitment Therapy (ACT), and Exposure therapy, the therapist helps the person acquire skills to move toward living the life they want to live, instead of being pushed around by their anxiety.

Footnote:

* OCD and illness anxiety are not, strictly speaking, anxiety disorders, but they are very similar to anxiety disorders in their presentation and in the patterns of thinking and behaviour of the individuals who have them. There are also many similarities in the treatment approach for them and for anxiety disorders. They are outlined in separate categories of the DSM-5. 

To learn more about anxiety and effective ways of dealing with it in the long-term, read our anxiety blog.

If you enjoyed this article, follow me on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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Panic Attack Symptoms

A panic attack is an abrupt surge of fear or acute discomfort. It includes severe physical symptoms that escalate very quickly (usually within a few minutes).

The physical symptoms may include racing heart, clammy palms, shaking, dry mouth, shortness of breath, sweating, chest pain, dizziness, nausea, numbness or tingling sensations, and feelings of unreality or detachment.

The thoughts usually include a fear of dying, going crazy, losing control, or some other imminent catastrophe.

Although a person may have a panic attack when they are already anxious, oftentimes a panic attack starts seemingly out of nowhere, when one is in a perfectly calm state.

Some panic attacks are predictable and may happen when a person has to face a situation or trigger that usually causes high anxiety. Other panic episodes may come out of the blue. A person may even wake up to a panic attack at night (these are called nocturnal panic attacks).

How Long Do Panic Attacks Last

Panic attacks usually don't last very long. But they feel excruciatingly long, so people often overestimate how long their attacks last. The attacks develop and reach their peak extremely quickly, after which the symptoms start to subside.

Most panic attacks last up to 30 minutes. What often leads to the confusion about the duration of panic attacks is the question of what is considered to be the onset of an attack. Panic attacks, by definition, develop abruptly - within minutes. But when they develop from an already anxious state, the anxious state that preceded the attack does not count toward the time of the attack.

Another factor leading to the discrepancy in the perceived length of the attacks is related to what people do during the attack. Sometimes, a person will try very hard to calm down by breathing, distracting themselves, trying to relax, etc. This often leads to temporary relief of the symptoms but a subsequent increase of the symptoms. As counter-intuitive as it sounds, just "riding out" an attack without doing anything about it will lead to shorter attacks.

Panic Attack vs. Anxiety

Anxiety is usually related to a fear of a negative outcome or worry. It can develop relatively quickly or slowly.

Panic, however, comes seemingly out of nowhere and strikes rapidly. It is accompanied by severe, intense fear.

Panic Attack vs. Panic Disorder

‘Panic attack’ and ‘panic disorder’ are terms that are often used interchangeably. But they are not the same. The difference between the two is very important as it determines the course of the treatment.

You may experience numerous panic attacks without developing a panic disorder.

Panic attacks frequently happen in the context of a psychological disorder (Social Anxiety, Phobia, Illness Anxiety, Generalized Anxiety Disorder (GAD), Obsessive Compulsive Disorder (OCD), trauma, etc.). These attacks are related to the fear associated with the underlying disorder (a fear of a social situation, a specific object, acquiring a deadly disease, something bad happening in the future, etc.)

In these cases, a person usually will not meet the criteria for a panic disorder. It is then important to treat the underlying disorder (as opposed to panic).

For a panic disorder diagnosis to be established:

- A person must experience recurrent, unexpected panic attacks.

- At least one of the attacks must be followed by over one month of persistent worry that another attack will happen, and about its catastrophic consequences (having a heart attack or a stroke, losing control, going crazy, etc.).

- A person must develop maladaptive safety and avoidance strategies aimed to prevent the dreaded next attack from happening. These strategies typically involve avoidance of situations or monitoring bodily sensations that are associated with the attacks.

- The attacks and the safety and avoidance strategies are not better explained by the presence of another psychological disorder.

Diagnosis of a Panic Disorder

The first important task in diagnosing a panic disorder is to rule out a medical condition by visiting your doctor. Many people come to treatment after visiting an ER a few times with what seemed, and felt, like a heart attack. After cardiovascular (and respiratory, endocrine, etc.) disorders are ruled out, the person is usually referred to counselling.

After ruling out the physical causes, it is important to see a psychologist or other mental health professional for a proper differential diagnosis.

Agoraphobia

Agoraphobia is a fear of and attempts to avoid some of the following situations:

- Using public transport (cars, buses, subways, planes)

- Being in either open or enclosed spaces

- Standing in line

- Being in a crowd

- Being outside of the home alone

The fear is caused by the thought of the inability to escape the above situations in case of a panic attack. As you can see, even though agoraphobia can be diagnosed as a separate disorder, it is related to the fear of having a panic attack and, therefore, it is often diagnosed as secondary to a panic disorder.

In extreme cases of agoraphobia, the person may become completely homebound.

Managing Panic Attacks and Popular Strategies that Don’t Work

There is an important difference between short-term, in-the-moment management (trying to get rid) of panic attacks and the treatment of panic disorder. In some ways they are, as strange as it sounds, the opposite of one another.

Breathing, relaxation, and grounding techniques can be very helpful in the moment. But if you truly want to overcome this debilitating condition, you need to seek a therapist specializing in exposure, which is a part of Cognitive Behavioral Therapy (CBT), as well as in Acceptance and Commitment Therapy (ACT). This treatment is very effective and has a high rate of success for panic disorder.

Beware of treatment plans that focus on anxiety reduction and attempts to get rid of your unpleasant physical symptoms. These may include:

- Distraction

- Positive thinking

- Deep breathing

- Relaxation

- Walking slowly so that your heart rate doesn’t go up

- Fidget toys or Silly Putty

- Closing your eyes

- Making sure to carry water with you and take sips if you feel the panic coming

- Picturing your happy/safe place

- Grounding techniques

- Counting

- Repeating a mantra

- Taking a benzodiazepine when you feel the symptoms approaching

If you have been in therapy, you may be surprised that the suggestions above are counter-indicative for the treatment of a panic disorder, as it is likely that these are exactly the techniques that were suggested by your therapist. Moreover, some of them may have even helped to prevent or stop an occasional panic attack.

So why, then, does the evidence-based treatment advise against using these techniques?

Evidence-Based Panic Disorder Treatment

As mentioned in the previous section, it turns out that the very techniques that may temporarily help manage a panic attack may also maintain or even strengthen the panic disorder in the long run.

The reason for that is that panic attacks, as unpleasant as they are, are not dangerous. It’s just our sympathetic nervous system over-reacting to a benign physical symptom.

But people suffering from panic disorder are hyper-aware of these normal bodily sensations and tend to misinterpret them as dangerous. This misinterpretation leads to anxiety, and anxiety creates even more physical symptoms. This, in turn, leads to even greater catastrophizing.

It goes like this:

Physical symptom → “Oh, no! I’m having a panic attack again!” → anxiety → more physical symptoms → “This must be a heart attack” → more anxiety, etc.

So, the person enters a vicious, rapidly escalating cycle of:

Sensation → thought → anxiety → sensation → thought →anxiety, etc.

To make matters worse, the person then usually tries to do everything possible to prevent further attacks from happening. This includes attempts to avoid threatening situations and physical sensations.

Whenever avoiding a situation or a sensation is impossible, the person resorts to various safety strategies, such as always carrying water or anti-anxiety meds, trying to stay relaxed, monitoring their breathing, sitting close to the exit at the movies, avoiding highways or bridges, asking for reassurance, looking for distractions, seeking fresh air, etc.

These strategies further reinforce the belief that the physical symptoms are unbearable and dangerous. The person also usually feels better when avoiding or using safety strategies, but then he or she attributes this relief to the above strategies and never gets to find out that the panic attack would have subsided on its own. This keeps the panic disorder going.

Another pattern that maintains panic is monitoring the physical symptoms. This may include checking heart rate, pulse, and breathing, watching for signs of dizziness, or trying to swallow. This selective attention leads to hypervigilance and to more frequent and heightened experiences of the symptoms.

As you can see, these maladaptive attempts to control anxiety look very similar (identical?) to the strategies that are often used in therapy and are promoted in the media.

Main (Real) Treatment Steps

1. The treatment of a panic disorder always starts with teaching you, in detail, about how panic develops and how safety and avoidance behaviours, as well as selective attention/monitoring, keep the panic disorder going.

We need to demystify panic in order to perform the counterintuitive strategies that are required to overcome it, and to gather the courage to get rid of avoidance and safety behaviours.

2. The next step involves gradually getting rid of avoiding threatening situations. This takes a leap of faith, but also usually produces very empowering results as your world expands and you gain confidence.

3. Another vital step is giving up your safety behaviours. You can give them up progressively, or you can go cold turkey. Either way, you have to learn that you don’t need crutches to cope with normal bodily sensations.

4. Simultaneously with the steps above, you will work on radically changing your relationship with discomfort – whether it is caused by physical symptoms or thoughts. You will develop skills to help you give up the futile agenda of trying to get rid of unpleasant physical sensations. Instead, you will learn to take steps toward the life you want to live regardless of how you feel at the moment, and of the thoughts that pop up in your mind.

A good side effect of this step is that it is effortlessly transferrable to other areas of your life and makes it so much easier to move toward your life goals in all life domains.

5. Moreover, in line with all the above, the treatment will involve practicing voluntarily producing your symptoms.

Remember how we said that trying to get rid of a panic attack is the opposite of treating a panic disorder? When your goal is to get rid of the symptoms, you learn that they are dangerous and should be avoided at all costs. This learning feeds the panic.

But when you practice purposely being uncomfortable or even scared, you quickly learn that no catastrophe is taking place. These symptoms are unpleasant, but harmless. Diligently practicing these exercises quickly leads to breaking your vicious panic cycle.

Have you been suffering from panic attacks? Please share your story in the comments below!

If you enjoyed this article, follow us on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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What is Illness Anxiety?

Illness anxiety (formerly known as hypochondriasis and health anxiety) is a preoccupation with having or getting a serious disorder despite having no symptoms or only benign symptoms.

People suffering from illness anxiety engage in behaviours aimed to reduce the fear/anxiety of becoming ill or to obtain certainty that they are healthy. Such behaviours include checking and scanning their body for potential symptoms, going to numerous medical appointments (or, in other cases, avoiding doctors and medical appointments), taking too many medications, as well as repeatedly asking for reassurance that they are not ill. This preoccupation gradually takes over a person's life and severely interferes with their daily functioning. 

No amount of medical reassurance or negative test results relieves their anxiety. Sometimes the sufferers become even more concerned after being reassured by a doctor as they contemplate the possibility of the doctor not taking them seriously, not being knowledgeable enough, or mixing up the medical test results.

There are two types of illness anxiety: care-seeking and care-avoidant. People often present with a mixture of the two types – switching between excessively seeking medical care and information at certain times, and avoiding it at other times.

An illness anxiety sufferer’s fear can shift between a fear of acquiring a disease or a fear of having an actual disease.

Even though the DSM-5 lists illness anxiety in the Somatic Symptom and Related Disorders category, its presentation and treatment are very similar to the presentation and treatment of Obsessive-Compulsive Disorder (OCD).

In the case of illness anxiety, the intrusive, unwanted thoughts about having a disease are the obsessions, while the behaviours aimed to reduce the anxiety are the compulsions. As with OCD, the more checking one engages in, the worse the person feels; the more reassurance is sought, the less reassured the person becomes.

 Thoughts (Obsessions) that are Common in Illness Anxiety

 “I may miss an important symptom.” This thought is related to two common OCD features – an inability to tolerate uncertainty, and an over-inflated sense of responsibility. People who have these thinking patterns feel that they have to do everything in their power to know for sure if they have the feared disorder. They also feel that they won’t be able to live with the thought that they are responsible for not catching the disorder in time. 

“I have to be 100% certain that I don’t have a disorder.” Again, this is the endless and unattainable quest for absolute certainty.

“Doctors often miss serious disorders.” And: “I can never completely believe a doctor or test results because so many mistakes happen.“ This thought leads to endless doctors appointments, as well as going from one specialist to another and seeking second, third, and fourth medical opinions. 

“If I feel concerned, then there must be a reason for it.“ This is a common thought related to perceiving feelings as facts.

“I should check every concerning symptom numerous times a day.” This one quickly gets out of control and the days are spent in never-ending checking. 

Some more specific examples of illness anxiety thoughts:

 -          “This mole seems darker than it was yesterday. Surely, it’s melanoma!”

 -          “This is my second headache this month. I better Google brain tumour symptoms.” 

 -          “My urine/saliva is a different colour today. What if I have internal bleeding?” 

 -          “My doctor looked distracted at the last appointment. He could have missed the abnormal results of my tests. What if he didn’t listen to what I told him?”

 -          “The doctor paused for a second and looked at me. Does she suspect that I have something serious going on with my health?”

 -          “My doctor told me to get another test. She knows I'm gravely ill but doesn't want to tell me.” 

- “I should get a second (third, fourth) medical opinion”

 -          “My doctor refused to refer me to do the test I requested. He doesn’t take my symptoms seriously and will for sure fail to catch this disorder until it’s too late. I better consult with another specialist.”

In addition to the common thoughts above, people with health anxiety often refuse to accept the fact that they have a psychological condition. They fear that if they accept that this is their main problem, they will lose their vigilance and may miss a “real” physical health problem.

Patterns that Reinforce Illness Anxiety

• All-or-nothing thinking:  Seeing things in black-and-white terms, such as, “I’m either healthy or seriously sick” or “I can only know for sure that I’m healthy if I have absolutely no uncomfortable bodily sensations.” 

• Catastrophizing:  Attributing catastrophic consequences to minor things, for example, “If I have a symptom, it must indicate a horrible disease”, “I have a headache. This must be a brain tumor” or “A scratchy throat means I have throat cancer.”

• Intolerance of uncertainty:  Striving to obtain absolute certainty and refusing to accept that everything in our life is uncertain, for example, “I must be 100% sure that I’m healthy. If I am not 100% sure, that means I must be seriously ill. So, I’ll investigate until I achieve the feeling of 100% certainty.”

• Emotional reasoning:  Perceiving feelings as if they were facts, for example, “I feel that there may be something wrong with my health. Therefore, I must be ill.”

• Unwillingness to Tolerate Discomfort: Feeling that the discomfort will never end, will be unbearable, it’s impossible to cope with it, and impossible to function unless the discomfort disappears.

Some people with illness anxiety start worrying about their health after a health-related negative experience. They may have watched a loved one have a serious illness or die, or they themselves may have had a serious disease, or, often, they may have witnessed a doctor making a mistake or missing a symptom.

Typical Illness Anxiety Behaviours (Compulsions)

 -      Repeatedly monitoring and checking the symptoms (which creates even more bodily sensations).

-       Asking family members to have a look at the symptoms.

-       Asking questions about various possible symptoms and their meanings. 

-       Repeating the same symptom-related questions and asking for more information, and then going back and asking for even more information.

-       Seeking endless reassurance related to medical symptoms.

-       Frequently going to doctors' appointments, which often leads to doctors’ recommendations to monitor the symptoms, which further increases the checking compulsions.

-       Providing overly lengthy, detailed descriptions of symptoms during medical appointments, then worrying after noticing that the doctor became distracted and/or impatient.

-       Frequently requesting unnecessary medical tests.  

-       Seeking second, third, and fourth opinions and trying to finally find a doctor that will agree with them.

-       Asking other people which symptoms they consider "normal" and which ones would be a concern for them.

-       Comparing their symptoms to other people’s symptoms.

-       Excessive browsing illness-related information.

-       Avoiding anything illness-related (doctors, hospitals, medical tests, medical information).

-       Avoiding places where a contagious disease may be acquired (hospitals, waiting rooms, etc.) .

-       Overly rigid health-related routines in terms of exercise, diet, and vitamins.

Illness Anxiety Treatment

The most effective treatment for illness anxiety is Cognitive Behavioural Therapy (CBT), specifically, Exposure with Response Prevention (ERP).

In our experience, CBT and ERP for illness anxiety are more effective when combined with Acceptance and Commitment Therapy (ACT). ACT helps people change their relationship with anxiety and discomfort and make conscious choices that allow them to take steps toward a rich and meaningful life, without succumbing to illness anxiety’s demands.

As with other types of OCD, the treatment focuses on confronting the thoughts and situations that trigger anxiety while not engaging in behaviours aimed at reducing anxiety.

The goal of the treatment is NOT to convince you that you are not sick but to help you change your relationship with anxiety and learn that you can tolerate the uncertainty and the fear of being responsible for missing a symptom.

What You Can Start Doing Today to Overcome Your Illness Anxiety

 If you have illness anxiety, you know that all the behaviours mentioned above temporarily reduce your anxiety, but then it keeps coming back and becomes even stronger. Furthermore, over time, you have probably come to need even more of these rituals to experience relief. Every time you do a compulsion (a behaviour aimed at reducing your distress), you are feeding your anxiety and making it stronger.

 Your attempts to control or eliminate your discomfort lead to a vicious cycle of intrusive thoughts and rituals. As you experience a temporary reduction of distress when you act on the compulsions, you learn that you are unable to cope with your anxiety unless you engage in the ritual. This, by itself, perpetuates more anxiety and leads to even more compulsions.

 Here are Six Steps to Dealing with Illness Anxiety:

1.    Write a list of what you have sacrificed to illness anxiety so far. Be as specific as possible. How has it affected your relationships? Your productivity? Your ability to have fun? Your finances?

It may take you a few days to complete the list as you may not be immediately aware of all the areas of your life that have been affected.

Review your list and reflect on whether the price that you are paying for your seeking health-related certainty is too high. Are you willing to start rebelling against your illness anxiety to reclaim your life?

The list is a reminder that it is not the feared disease that is ruining your life; it’s your illness anxiety that is currently causing your suffering.

Keep the list handy and refer to it for motivation when you practice the strategies below.

 2.    Write a list of all the things you have been doing to try and reduce your anxiety. Try to write down as many examples as possible. Refer to the “Typical Illness Anxiety Behaviours” section above for help.

Again, it may take you several days to identify most of the external and internal compulsions that you have been doing.

Now, assess whether any of these compulsions have brought you long-term relief from your illness anxiety.

 3.    Eliminate, or at least significantly reduce your rituals and habits. Will it be easy? Of course not. You know that the urge to check or ask for reassurance is overwhelming. You also know that the sense of terror and urgency you experience when you feel you may get the dreaded disease is difficult to endure. But, nevertheless, with practice, it is possible to reduce illness anxiety behaviours. Moreover, as you continue reducing the rituals, you will start experiencing a sense of mastery, well-being, and pride as illness anxiety obsessions will push you around less and less.

You can eliminate the behaviours in a cold-turkey approach or gradually. It’s really up to you.

If you decide to proceed slowly, you can start by reducing the frequency of rituals by a third every week or every couple of weeks until you stop doing them completely.

 Some examples:

 -       If you currently check your symptom 30 times a day, start by reducing the checking to 20 times. You can put checkmarks or numbers in a Notes app on your phone to count the checking.

-       Talk to your doctor and explain that you are trying to overcome your illness anxiety. Ask the doctor for guidelines on how many visits a year a person with your health history typically needs. Then, start working toward that number of visits.

-       Reduce the number of times per week (or per day) you ask for reassurance. You can print out these reassurance coupons and limit yourself to eight coupons per week. Please read the instructions for using the coupons here.

-       Cut out all health-related internet searches.

 Of course, every single illness anxiety sufferer will wonder, “But what if it’s a slippery slope? What if in the course of trying to overcome my illness anxiety, I do miss an important symptom? What if I’m actually right that I’m sick?” The answer is -- this is always a possibility and this is a risk that you have to take to reclaim your life.

When you question yourself like this, review your list of things that you have lost to your illness anxiety. Are you willing to continue giving them up? If not, you have to accept that life is not risk-free. To help yourself with that, proceed with the next step and …

 4.    Challenge your need to have certainty (This is the intolerance of uncertainty thinking trap that was mentioned earlier)

The usual pattern of coping with uncertainty is trying to achieve certainty by all means, such as attending doctors’ appointments, checking and monitoring the symptoms, asking for medical tests, seeking reassurance, etc. Unfortunately, as you learned the hard way, this sense of certainty that you are after is ever elusive and, even if you feel some relief after being reassured, it is short-lived.

 A much more effective strategy is to work on increasing your tolerance of uncertainty. After all, everything in life is uncertain. Absolute certainty is an illusion. It doesn’t exist.

We accept the uncertainty and the risks associated with it every time we drive, cross bridges, take elevators, eat in restaurants, and send our kids to school. In order to overcome illness anxiety, it is crucial to accept health-related uncertainty as well. Read more about tolerating uncertainty here.

 5.    Learn strategies to disengage from intrusive, health-related thoughts as you go about your day. If you have an intrusive fear-driven thought, say, “I’m noticing that I’m having a thought that this mole may be cancerous.” The anxiety may or may not subside. It doesn’t matter if it does or not – this is not the goal here. The goal is for you to take a tiny step away from the thought instead of immediately and impulsively reacting to it.

 Other disengagement strategies:

-       Imagine that the thought is an annoying call by a telemarketer, which you can decide not to answer.

-       Say to yourself, “Oh, this is the ‘cancer story’ again.”

-       Imagine the thought being written in different fonts on a computer screen.

- Thank your mind for trying to be helpful and refocus on what you’ve been doing.

 Important note: Disengaging or unhooking from thoughts does not equal trying to stop them. Actually, it is the opposite of thought-stopping. When you try to get rid of thoughts, this implies that they are dangerous and you need to stop them. But disengaging means allowing the thoughts to come and go without trying to do a thing about them.

 6.    Find a radically new way to respond to anxiety. You have tried many methods to reduce your distress by engaging in compulsions, and you know it doesn’t work in the long run. Instead of continuing to play tug-of-war with your distress, let go of the rope -- change your relationship with distress by accepting it without trying to get rid of it.

 Stay with your anxiety or distress. Don’t try to push it away. Instead, let it come and go on its own. Practice it willingly. Examine your thoughts and feelings that accompany distress with curiosity.

 When you become more used to not pushing your anxiety away, up the ante and start facing your anxiety on purpose. Think the dreaded thought (such as, “I may miss a symptom of cancer and it will then be too late to treat it”). Keep thinking this feared thought without resorting to any safety behaviours. This helps you learn that you can have the thought and do absolutely nothing about it.

 If it’s specific places or situations that you are avoiding, then start facing them. Stop sanitizing everything, touch chairs in hospital emergency rooms, sit for an hour at a waiting room of a medical office, etc.

 In our clinic, we hand out clickers to our patients with an instruction to click every time they consciously choose to willingly increase and accept their anxiety. This is oftentimes a game-changer for anxiety or OCD sufferers as they learn to develop a playful attitude toward their intrusive scary thoughts and, thus, stop living their lives feeling controlled by their intrusive thoughts.

Do you suffer from illness anxiety? Have you recognized some obsessions and compulsions that you have? Share your story in the comments below!

If you enjoyed this article, follow us on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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You have probably heard about Catfishing – online scams that take advantage of people looking for love online. The scam is very simple. A scammer creates a fake online profile using a fake name and fake pictures. He usually claims to be deployed or working in a foreign country. When the scammer starts talking to you, he or she will go to great lengths to gain your trust and tell you everything you want to hear. The scammer will tell you how beautiful and desirable you are and how much they love you. They will send you love poems and songs (usually stolen from other web sites).  They will start making plans for your future together and talk about meeting in person.

At some point, the scammer will usually ask you to send them a small sum of money claiming that they are in an emergency situation. By that time, you feel that you know and trust this person and the amount of money is very small, so you are happy to help them out. After all, this is your soulmate and you plan to spend the rest of your life with them. This is usually just the first request and is soon followed by increasingly frequent and escalating requests for more money. If you start hesitating to send the money, the scammer becomes more persistent and will make you feel guilty for abandoning them in a difficult situation. And if you do send the money, then yet another request is sure to follow.

The more you invest in this “relationship” both emotionally and financially, the more you are likely to continue in it, as it always seems that only a tiny, little last obstacle remains that separates you from finally meeting the love of your life. You feel like you are just one money transfer away from your life of happiness with your soulmate.

As you are reading this, you are probably thinking smugly that this can never happen to you and only naïve, gullible people can fall for this scam. You would for sure identify the red flags early on and just say “no” to the scammer’s sneaky methods.

But isn’t this exactly how you fall prey to OCD’s demands time after time? Your OCD is pretending to be your friend, whose goal is to protect you from danger or distress. If only you do what it tells you, just this one time – you will feel so much better, you and your loved ones will be safe, and you’ll be able to continue with your day. Just this one time. Just this one ritual. If you try not to comply, OCD becomes increasingly persistent and increasingly loud. And when you do comply, then it’s a matter of a very short time until it asks you for something else.

Your best chance to avoid becoming the victim of a scam is to never send money to somebody you’ve never met in person. The more persistent they become and the more pressure they apply, the more it should be clear that this person does not have your best interest in heart. You can’t avoid the scammer’s emails, texts, calls, and messages, but you can continue with your life regardless of them, not succumbing to the scammer’s demands.  

Why not take a similar approach in responding to OCD’s conniving ways? By now, you know very well how it operates. The more strategies you implement with the goal of avoiding the feeling of discomfort, the stickier OCD thoughts become. You can’t really control these thoughts and feelings because it’s impossible. But, you can live your life and do the things that matter to you in spite of these thoughts and feelings.  

Will the scammer’s or OCD’s demands go away? They may. Or they may not, as scammers can be very persistent. When you stop engaging with them, though, you stop being their prisoner and can refocus on the things that matter in your real (not imaginary) life.

OCD treatment involves understanding how OCD keeps tricking you and learning to refuse to obey it. This treatment is called ERP – Exposure with Response Prevention (which is a part of CBT – Cognitive Behavioral Therapy). It is often combined with ACT – Acceptance and Commitment Therapy for increased effectiveness. When you engage in ERP and ACT, you learn to face triggering thoughts, feelings, urges, and situations without engaging in compulsions (that is, without accommodating OCD’s demands). The treatment is very effective and can be life-changing for OCD sufferers.

Enough with the scammers. It’s time to stop listening to their demands and reclaim your life!

Has OCD been trying to scam you too? Share your story in the comments below!

To learn more about anxiety and effective ways of dealing with it in the long-term, read our anxiety blog.

If you enjoyed this article, follow us on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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A Quest to Find Offensive Stuff

An occupational therapist colleague of mine, Victoria Prooday, recently posted an image on her professional Facebook page. The cartoon picture showed two people sitting at the opposite sides of a bus. One side of the road faced a sunny landscape and the person sitting on that side of the bus was smiling happily and taking pictures with her phone. The other side of the road faced a gloomy mountain and the person sitting there, observing the uninspiring view, looked sad and miserable. The caption under the picture read: “So much of our happiness depends on how we choose to look at the world.”

Victoria added a commentary that happiness requires a conscious effort and that there is always a choice that we can make in our attitude.

Within minutes, this innocent little inspirational post gathered comments from people accusing Victoria of shaming those with depression. The commenters passionately advocated against offering people with depression the tools to try and overcome their difficulties, explaining that this sent the message that depressed people are the ones to blame for not making the right choices.

One commenter stated (correctly) that depression was not a choice. She then inferred that, therefore, even evidence-based treatments for depression could be counter-indicated for some people who, instead, would benefit more from “compassionate understanding.” When another person, who experienced depression herself, commented that similar information to the cartoon helped her overcome her own depression, she was told that others may still be harmed by such advice.

As a psychologist treating anxiety and depression, I couldn’t help thinking about the implications of this relatively new, but very common attitude toward mental illness. It seems that there is a mob of people constantly browsing through anything that is said and written about psychological health with the goal of finding something shaming, triggering, oppressive, blaming, or offensive. And, alas, when we approach life with this attitude, we, of course, find what we are looking for.

The Unintended Consequences of Radical Acceptance Preaching

As these self-appointed mental health advocates are usually very vocal, many people, including health professionals and teachers, structure and censor their verbal and written communication with the goal of avoiding an outlash. Therapists often offer endless validation, instead of gently and collaboratively creating a roadmap for change. Psychologists provide diagnoses and recommend numerous school accommodations.  Teachers take the accommodations even further and often create additional adjustments themselves. Parents, believing that they should endlessly fight and advocate for their child against stigma and shame, negotiate further modified assignments and extended deadlines.  

Suggesting healthier nutrition? – You are fat-shaming. Offering strategies for weaning off an anti-anxiety medication? – You are pill-shaming. Proposing more structure, discipline, and routine for a child? – You are parent-shaming.

Unfortunately, the current over-zealous censorship inevitably leads people to believe that they are irreparably damaged, broken, or flawed, -- creating a feeling of worthlessness, helplessness, and hopelessness. People learn to believe that there is no internal agency for change and that all they have left is venting and relying on external accommodations. This disempowering effect is overlooked. 

Is Acceptance Necessary?

Does this radical acceptance have a place in helping a person move toward a better life? Of course, it does! It’s difficult to make progress without first accepting where we are right now. People need a non-judgemental, compassionate environment where they can talk about their pain. They need somebody to listen to them and to empathise. And accommodations are often needed – sometimes permanently, and sometimes temporarily.  

Is Acceptance Sufficient?

The point that keeps getting missed is that by themselves, the validations and accommodations don’t achieve much. They are necessary, but not sufficient. They are just the first step on the way to growth, recovery, change, and living the best life. The steps that need to follow are specific actions toward the life that a person finds meaningful. Choosing to see other people’s statements as offensive instead of approaching them in good faith leads to the loss of these essential nuances.

As a society, we have finally come to a very important stage of accepting mental illness. There is a lot of the much-needed talk about increasing awareness and reducing the stigma of psychological disorders. But should we just leave it at that? Or are there more steps?

A War on Change.

Meanwhile, somehow, the noble goal of acceptance and non-shaming has turned into a war on change. And, ironically, it has also turned into shaming the very people who have the ability to help the sufferers of psychological disorders.

This is how therapists and authors had to stop using the now-forbidden P-word (punishment) and replaced it with “consequences.” Recently, the “consequences” word has also fallen out of favour and parents are encouraged just to listen to the child and try to be understanding.

No wonder that we see so many parents feeling completely helpless about disciplining their children. They were led to believe that accepting the child the way she is would be enough. But it isn’t. Children need routine, discipline, and guidance.

Building internal strength and resiliency when coping with a difficult boss or family member are replaced by launching complaints about the boss and severing the ties with a “toxic” family member. Are those sometimes justified? Yes, for sure they are. But in many non-extreme cases, internal coping skills can be developed to handle those situations without being emotionally hurt. And, those skills are invaluable and transferrable to other problematic circumstances.

The evidenced-based strategies for depression (behavior activation, cognitive restructuring, learning to make steps toward values and goals in spite of painful feelings and thoughts) are suddenly considered shaming and judgemental. “It IS shaming to tell someone with depression that they have a choice about it,” the Facebook commenter proclaimed, quickly moving to calling “positivity advice” to be a “near-enemy of true compassionate understanding.” Yes, nobody chooses to be depressed. But within depression, addiction, and any other illness or life situation, there is always an element of choice of what to do about it. Sending the message that the choice is not there is dangerous and irresponsible.

The Only Way Out of Fear, Anxiety, Depression, Life’s Difficulties, and Pain is Through Them.

No amount of support or reassurance will help a person to overcome an anxiety disorder or OCD. Worse than that, as any therapist trained in the treatment of those disorders knows, accommodations and reassurance will make a person feel better for a very short time but will lead to a gradual worsening of anxiety.

Similarly, it is very difficult to overcome depression without increasing the levels of activity in spite of a complete lack of motivation to do so. And, going back to the example of school accommodations, in most cases those are temporary Band-Aid solutions and will not lead to any significant improvement without numerous other changes in the child’s routine, discipline, self-regulation, and nutrition.

I don’t doubt that the trigger-searchers’ intentions are noble. They would like everybody to accept themselves without changing a thing. On a deeper, psychological level, it also feels really good to perceive oneself to be a non-judgmental and accepting person. Unfortunately, it’s the psychological disorder's sufferers who pay the price for this beautifully-sounding un-nuanced ideology. 

And this is where the question of what compassion is comes to mind. Compassion does not mean enabling somebody so that they can experience a temporary relief which will lead to long-term worsening of their problem. If we have an honest look at ourselves, we do it to feel instantly better. It’s not much different from giving in to a toddler tantruming in a supermarket and buying him a candy knowing full well that it’s not good for him. But it sure makes us feel good, brings relief, and “resolves“ an uncomfortable situation.

Real compassion is tolerating our own discomfort while working to help another person to live a meaningful life in spite of their past and in spite of their painful emotions and thoughts. This is true kindness. In today’s climate, it also means, tolerating the implicit judgement and explicit criticism of well-meaning bystanders who recoil when they encounter pain and whose knee-jerk reaction, therefore, is to make it disappear.

Acceptance of our limitations and pain is only the first step. The next steps are identifying which value-driven direction we would like to move toward to, dealing with the obstacles that stand in the way, and committing to taking effective action to create a rich and meaningful life.

If you enjoyed this article, follow me on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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How do I know if I have Social Anxiety, or Maybe I’m Just Introverted or Shy?

Social anxiety (also known as Social Phobia) is a misunderstood condition. People often confuse it with being introverted or shy. But introverts are not by definition socially anxious. A person can be perfectly comfortable around people but may not enjoy loud gatherings. While extroverts feel energized after crowded get-togethers, introverts feel depleted and need to recuperate. Introverts, therefore, prefer solitary activities but do not suffer from social anxiety. They may stay home on a Friday night feeling perfectly content.

On the other hand, socially anxious people can easily be extroverts. They may crave the company of others and long to be a part of a social group, but they stay away because of their fear of being judged by others.

As to the difference between social anxiety and shyness, even though there are similarities in the behavior of people with social anxiety and shy people, shyness is a personality trait and does not necessarily lead to suffering. Social anxiety, however, is not a trait. It is a diagnosable, pervasive, and chronic disorder that causes significant distress or impairment to the person's functioning and affects many areas of a person’s life.

Why So Many People Continue Suffering from Social Anxiety and Don’t Seek Treatment

The confusion between introversion, shyness, and social anxiety minimizes the perceived impact of this condition on both the sufferers and those around them. Well-meaning friends and family members will often try to support their loved ones by saying something along the lines of “Just relax and have fun!” or “Come on, it’s all in your head!” But, as any social anxiety sufferer knows, those statements just lead to the feeling that nobody really understands them, which often makes them feel even more isolated. Such statements reinforce the belief that there is really nothing wrong, and that the anxious person just needs to cheer up a bit.

Parents insisting that their socially anxious kid is just shy also minimizes the problem and underestimates the child’s very real and very deep distress.

Social stigma is another factor as to why people go for so long without treatment. It is more socially acceptable to be introverted, or shy, than to have a diagnosable disorder.

Most anxiety disorders do not resolve on their own, and social anxiety is no exception. In today's computerized world, it is easier for people with social anxiety to hide behind their screens. Therefore, not only are they less likely to seek out treatment, but their anxiety often worsens with time.

A vicious cycle develops: socially anxious individuals try to avoid in-person social interactions at all costs, and the more they avoid, the more anxious they become.

The major part of the treatment for social anxiety includes facing social situations without resorting to “safety” behaviors. In the past, routine daily life activities themselves provided multiple daily opportunities for such social contact. Up until very recently, kids and teens naturally interacted more with their peers, thus addressing their social anxiety without even knowing it. It also allowed parents and teachers to notice a socially anxious kid and try to help. In today's world, it is easier than ever to communicate with others without needing to face them. So it's not surprising that both kids and adults go untreated for very long. 

What Exactly is Social Anxiety?

Social Anxiety Disorder is characterized by the fear of being negatively evaluated, scrutinized, or judged by others in social situations. This fear could be related to a variety of social interactions or only to specific situations such as public speaking, meeting unfamiliar people, or even eating or drinking in front of others.

People with social anxiety fear that they will be humiliated, rejected, or judged, especially if they show their anxiety symptoms or act in an odd, embarrassing, or inadvertently offensive way. They may also fear being perceived as not smart or as incompetent.

Socially anxious individuals try to avoid feared social situations as much as possible.  In cases when it’s impossible to avoid, they try hard to behave in ways that will mask their embarrassment, self-perceived awkwardness, and anxiety.

Common Situations That Trigger Social Phobia Symptoms

-       Being the center of attention

-       Meeting or being introduced to new people

-       Attending a party

-       Having to talk in a formal, public, or group situation

-       Presetting in front of a group of people

-       Talking to an authority figure

-       Making small talk

-       Talking, eating, drinking, reading aloud, or writing in front of people

- Using a public washroom (a shy bladder syndrome)

Treatment for Social Anxiety

The good news is that we now have a very effective treatment of social anxiety. Cognitive Behavioral Therapy (CBT) is an evidence-based, short-term treatment with a very high rate of success for this disorder. 

People with social anxiety are afraid of being scrutinized, negatively evaluated, or judged by others. Evidence-based strategies for treating social anxiety address four patterns that characterize socially anxious people. Those patterns are:

1.    Self-focused attention. Socially anxious people are highly attuned to their internal symptoms and feelings, as well as how they imagine being perceived by others. This “tuning in” interferes with their social interactions. Their attention is tuned inwards and they miss numerous important verbal and non-verbal social cues.

2.    Avoidance and safety behaviors. Individuals with Social Phobia try to avoid situations that make them anxious, and when they can't do that, they often implement safety behaviors to cover up their anxiety signs. They may stare at their phone or look disinterested in order to avoid communicating with others, carry water everywhere, wear clothes that conceal sweating, or wear their hair down on their face to hide blushing. 

3.    "Postmortem" analysis of social situations. People with social anxiety often have persistent negative and unpleasant thoughts and images about their social interactions. They spend a great deal of time recalling how horrible they looked and sounded and imagine other people judging and rejecting them.

4.    Biased self-image. Socially anxious people believe that if they feel anxious or awkward, they must appear as such to others. 

6 Effective Evidence-Based Strategies for Overcoming Social Anxiety.

Overcoming those unhelpful patterns brings fast relief. Some very effective strategies are:

1.    Stop avoiding social situations. On the contrary - start actively seeking them. If you are very anxious, begin with having conversations with telemarketers or returning purchases to a store. This will help you habituate to social interactions. Then, start gradually exposing yourself to social interactions; first one-on-one, and slowly building the courage to interact with groups of people.

Other small steps to overcome avoidance may include:

-       Make it a goal to smile and say hello at every opportunity (at a store, in an elevator, at work, and in your neighborhood).

-       Identify the eye color of every person you talk to throughout the day to get used to establishing eye contact.

-       Try to learn at least one new person’s name whenever possible (at work, at a yoga class, or at an event).

2.    Examine the situation objectively. Remember, your feelings and thoughts are not facts, and the "how I feel is how I look" approach is incorrect. The information from your internal sensations is biased. How we feel inside is not an accurate reflection of how we come across to others. 

3.    In a social situation, keep shifting your focus to what's going on around you instead of focusing on your internal sensations and thoughts. Shifting attention away from the self and concentrating on others instead facilitates social interaction and helps you stay engaged. Make a conscious effort to look at the other person’s face, establish eye contact, and concentrate on the content of the conversation.

4.    Drop any "safety behaviors" you may be using - such as avoiding eye contact, staring at your phone, carrying a bottle of water, pretending to be disinterested, dressing or styling your hair a certain way, etc. They may seem helpful, but in reality, they just make anxiety stronger in the long run. 

5.    Ban the "postmortem" analysis and overthinking by not engaging with the thoughts and images of recent social interactions. You may start by allocating a certain time frame, say, 15 minutes per day, to “analyze” past social interactions. But, when you start thinking about them at other times, gently remind yourself that if you still need to, you will allow yourself to ruminate about them during the allocated time.

6.    Do not try to adhere to any specific social rules, as this will just make you more focused on yourself rather than the situation. The best social skill is to attend to the situation and to be flexible in your response. 

It is important to know that breathing, relaxation, and other safety behaviors only have a very limited and short-lived effect. If you have social anxiety, you need to stop avoiding social situations and structure your behavior for success by practicing the strategies above. 

How We Can Help Our Kids Avoid Developing Social Anxiety

As a society, we are getting better in terms of effective psychological and medical treatment and reducing stigma, but we are simultaneously falling behind as younger people become increasingly socially isolated.  

Raising awareness from the beginning of elementary school will help both reduce stigma and identify mental health problems earlier. Kids and teens often have school assignments on mental health disorders, which they then discuss in class and find thought-provoking and interesting. Kids often choose to do a project on the issue that they themselves are experiencing, which helps them become better educated about the treatment options, and to feel less lonely and stigmatized, and more hopeful. 

Additionally, strongly encouraging social connection and activities that do not include screens is a significant part of managing social anxiety in kids and teens, as well as adults.

Tips for Parents of Socially Anxious Kids

-       Be supportive of the child, but not of his anxiety. Instead of announcing to everybody that “he is just a little shy,” encourage the child to take small steps toward social interactions.

-       Acknowledge your child’s feelings and team up with her against the anxiety.

-       If necessary, move in very slow steps. You may start from working with your child toward saying hello to people she knows and to family members, then working toward practicing saying hello to a neighbor, a cashier, and other less familiar or completely unfamiliar people. Try to expose your child to a variety of situations and places and help her gain confidence.

-       Invite a child’s peer to a play date at your house. After your child becomes comfortable with his friend, invite another kid to join them. You can also arrange a playdate for the child at the friend’s house so that he can experience a social interaction at an unfamiliar territory.

-       Assign the child the responsibility of answering the home phone. Yes, this includes talking to pesky telemarketers, which is a great opportunity to practice engaging in a social interaction.

-       If you are shopping or going out together, use every opportunity to have the child ask for directions, find out where the bathroom is, or inquire whether the store carries another size or color. The child can also ask for a menu and order at a restaurant.

-       Teach your child not to believe everything he thinks. Encourage him to hold his thoughts lightly and not get too attached to them.

When we change our attitude from one of avoidance to one of seeking the challenge and overcoming it, things fall into place. Start now! Identify an anxiety-provoking social situation and set yourself up for success by actively engaging in it.

Do you suffer from social anxiety? have you found strategies or treatment that helped? Share your story in the comments below!

If you enjoyed this article, follow us on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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You did everything right.

You researched, you asked your doctor for a recommendation, and you went to a counsellor with the goal of finally getting rid of your anxiety.

The counsellor listened and emphasized. She was very nice and understanding. She worked with you on coping strategies. She asked you to believe in yourself. She encouraged you to be kinder to yourself and to practice self-care. She taught you the “grounding” technique. She asked you to practice positive affirmations throughout the day. She also taught you a thought-stopping technique for those times when anxious thoughts enter your mind. You came week after week and usually felt better after the sessions; but the anxiety always returned soon after the session.

You did more research and discovered that you need a therapist that practices evidence-based approaches, specifically, Cognitive Behavioural Therapy (CBT). It was not easy to change therapists, and you needed to re-tell all your problems from the beginning. Nonetheless, you were determined to get better and do the right thing by seeking help.

Your new CBT therapist asked you to complete numerous questionnaires to assess your anxiety. She looked like she knew what she was doing and you started to feel more hopeful. You spent your sessions in a very organized and scientific way – you examined the evidence that confirmed/disconfirmed your fears and calculated probabilities of “bad” things happening. You received worksheets to do both in-session and as homework. The therapist taught you abdominal breathing and progressive muscle tension and relaxation. You diligently filled in the thought records, worry diaries, and identified thinking distortions.

So why did you continue to feel anxious?

You started noticing a pattern. As you were driving home after a session, you felt reassured and relieved; you just calculated the probabilities of the horrible things that can happen, and examined the evidence that supported or disproved them. The probabilities looked very low. That made you feel so much better. After all, it was clear that whatever you were anxious about wasn’t so bad. The odds were in your favor! But as time passed, you started wondering, “What if, no matter how low the chance, this will still happen to me? That would be awful!” And the anxiety came back.

The thought-stopping helped, and with practice you were able to successfully push the thoughts out of your mind. Breathing techniques, relaxation, and positive thinking also seemed helpful. But the “bad” thoughts always came back – with a vengeance.

This left you confused and hopeless. You felt you really gave it your best, but you felt stuck.

You may feel this way if you suffer from moderate to severe anxiety, have persistent intrusive thoughts, or have been diagnosed with Obsessive Compulsive Disorder (OCD). In that case, the following common therapy tools will not work, which wouldn’t be so bad per se, but using them can also make your thoughts and worries more “sticky” and, thus, gradually make your anxiety worse.

Here is a list of common therapeutic techniques that will NOT work for severe anxiety.

1.    Thought stopping.

It may involve snapping a rubber band on your wrist or loudly repeating, “Stop!” It may work well for some people, but the effect is very short-lived.

2.    Positive affirmations.

A therapist may direct you to practice saying positive or happy statements throughout the day. This may make you feel more empowered at times, but at other times you’ll catch yourself thinking, “Who the hell am I kidding?”

3.    Distraction.

Trying to think about something else instead of the worrisome thoughts.

4.    Following the “Laws of Attraction.”

Thankfully, this craze is finally mostly behind us. I recall a time when clients came to me convinced that their thoughts attracted the “good” or “bad” things in their lives. Those people were terrified of bad thoughts. Ironically, this fear caused them to perceive those thoughts as meaningful, and the thoughts became even “stickier.” Truly, what you resist, persists!

5.    Coping strategies such as self-care and relaxation.

These are awesome and we all need them. Unfortunately, they are not treatments for an anxiety disorder.

6.    Examining the evidence for and against the thought.

This specific technique is a part of CBT, is well researched, and often effective. It can be a helpful addition to the treatment. Unfortunately, it is often practiced in isolation from other strategies and is unhelpful in those cases. To make matters worse, if it is used with more severe anxiety cases, such as Obsessive-Compulsive Disorder (OCD) or Generalized Anxiety Disorder (GAD) and is not combined with Exposure Therapy, it may lead to a worsening of the anxiety in the long term.

7.    Calculating the probability of the dreaded thing happening.

Again, it can be helpful sometimes; but if you are anxious enough, this will not resolve your worries. For example, those of us who are afraid of flying know that no matter how low the chances of a plane going down are, this doesn’t help us overcome our fear. Why? Because it’s the mere existence of that probability that makes us fearful, no matter how small the probability is. We don’t really concentrate on how unlikely it is; instead, we really zone in on how terrible it would be.

8.    Reassurance.

This could include convincing you that the chances of what you are afraid of happening are low. For example, if you live your life in fear of getting a serious disorder (in the absence of any concerning medical test results), the therapist may try to reassure you that there is no need for concern. Or, she may encourage you to avoid anything that makes your fear worse, such as reading medical articles or visiting a hospital. The treatment can also include examining the evidence (see #6). Even though it initially feels good to believe that you are safe, this feeling never lasts and usually the inevitable “...but what if…?” question creeps back up in a matter of hours or even minutes.

9.    Meditation explained the wrong way.

Meditation is a very effective tool in coping with anxiety. Unfortunately, though, many people have the idea that the goal of meditation is to get rid of the thoughts. This misconception usually leads a person to concluding that they are unable to meditate. If this is how you perceive meditation, to salvage the situation, you turn it into an attempt of thought-stopping (see #1). In reality, meditation gives you the opportunity to sit with your thoughts without engaging with them or trying to get rid of them. This gradually teaches you to accept the thoughts as non-threatening events.

10.    Advice to avoid stress.

Again, it’s not a bad idea to strive to live a balanced life, but in the context of anxiety disorders, this quest for a stress-free life can quickly lead to avoidance behaviours, which is one of the well-known factors that maintain anxiety in the long run.

All of the strategies listed above can be of great benefit to you if you experience temporary stress or anxiety related to life circumstances. Some of them can also be helpful if you incorporate them into your daily routine as long as you don’t use them for the purpose of getting rid of your thoughts.

But if you suffer from OCD or an anxiety disorder, all of those strategies used in isolation will just lead to those thoughts becoming more “sticky” and persistent. By trying so hard to get rid of them, you paradoxically make them stronger. Through trying to stop them, avoid them, argue with them, or figure them out, you just make them seem important and dangerous.

So, if those strategies aren’t helpful, why do you keep hearing about them everywhere – from friends, on the Internet, and even from therapists?

1.    The first reason is that those strategies are often effective in making you feel better in the short term. Unfortunately, their effect is not long lasting. Additionally, the more you do those things with the purpose of getting rid of anxiety, the more you keep your anxiety going.

2.    The second reason is that some of those strategies were popular years ago, before we had more solid research about how our brain works. An example of that would be snapping a rubber band in an attempt to stop an unwanted thought. The rationale behind that was that by punishing this “behaviour,” we’d do it less. Somehow, those strategies stuck. However, newer research, especially research on anxiety disorders, neuroplasticity, and exposure methods has led to much more effective therapeutic strategies.

3.    As stated above, those strategies can be helpful if you are just going through a difficult period in your life and do not suffer from an anxiety disorder. If this is the majority of cases that your counsellor sees, then she likely finds that they help people to overcome temporary struggles in their lives. This is not the case, however, for more serious anxiety disorders.

“Ok,” you may think, “great. So nothing really works and everything that I thought worked at least a little bit is apparently making my anxiety worse. What do I do now?”

This is your game plan:

1.    Accept the thoughts as they are. Trying not to think those thoughts, paradoxically, is a way of thinking about them and inviting them back.

2.    Continue to do things that you value in your life, in spite of the thoughts and fear. Don’t fight your thoughts. The more you fight them, the more they will come back. Let the thoughts and the feelings be in the background, and continue taking steps toward your goals.

3.    Face your fears. This is often the pivotal component that is missing from therapy.

4.    Accept that most things in life are uncertain.  Learn to live with the uncertainty instead of spending your life in the never-ending pursuit of more certainty.

5.    Start cultivating a completely new attitude toward anxiety, fear, and discomfort. Instead of fighting them, start inviting them into your life and see what happens.

Have you tried any of the strategies above in therapy? What worked? What haven’t worked? Share your story in the comments below!

To learn more about anxiety and effective ways of dealing with it in the long-term, read our anxiety blog.

If you enjoyed this article, follow us on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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  • Jan 22, 2019 Meet Anxiety. Anxiety: Part 1/7
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  • Dec 17, 2017 Anatomy and Physiology of Anxiety. Anxiety: Part 3/7
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We often underestimate how difficult it really is to get rid of anxiety. The fact is -- we are all evolutionarily predisposed to be anxious. Some of us more than others. Therefore, it’s not realistic to avoid anxiety altogether. But, more and more people feel that anxiety interferes with their daily lives, and they look for ways to function in spite of being anxious.

It’s important to remember that anxiety is not our enemy. Anxiety is what allowed our ancestors to stay away from danger, survive, and pass their genes onto us. So the problem is not anxiety, per se.

The problem is that we often perceive unknown things as dangerous. We also have a tendency to try very hard to avoid or push away anxiety -- an approach that may work in the short-term, but ultimately increases anxiety in the long run. 

The tips below will help you cope on days where you feel especially anxious. But, please keep in mind that the goal of these strategies is to help you get through the difficult times and to function at your best -- not to remove the feeling of anxiety from your life.

1.      Name the Emotion. Say to yourself, I am noticing that I'm feeling anxious. Sounds weird, I know. But this strategy helps redirect your brain activity from the "fear center" of the brain to the prefrontal cortex and thus, reduces the intensity of the emotion.

2.      Distance Yourself from the Anxiety. Want to reduce the intensity of anxiety even further? Then, extend your observation to your thoughts in addition to your feelings, I am noticing that I am having a thought that I feel anxious. This puts even more distance between you and anxiety, and helps you take a step away from it. It is useful to practice strategy #1 for a while, and when you become used to doing it, switch to strategy #2.

3.      Get Moving. Our body naturally gets activated when we are anxious (preparing to either fight or run in response to the perceived danger). Getting active is a great, healthy way to use up this restless energy. Go for a brisk walk, hold a plank for a minute or two, or do a few push-ups.

4.      Try Calming Yoga Poses. If you are not in the mood for active exercise, you can practice a few gentle restorative yoga poses. Remove your shoes, maybe close your eyes, and don’t forget to concentrate on your breathing while you sink into each pose. Some of the most helpful poses for anxiety are:

-          Standing forward bend: Stand with your feet slightly apart. Fold forward toward your toes with your back straight. You may bend your knees.

-          Legs up on the wall: Lie down near a wall with your hips as close to the wall as possible. Walk your feet up vertically onto the wall until you get into an L-shaped position. Bring your arms out to the sides.

-          Seated forward bend: Sit down with your legs stretched out in front of you. Stretch your arm forward and down toward your toes. 

-          Child’s pose: Sit on your heels and bend forward with your arms outstretched forward. Bring your torso to the floor and relax. 

5.      Breathe. Don’t try to breathe deeply as long inhalations may make you feel even more anxious. You need to concentrate on the prolonged exhalations. Imagine that you are blowing out a candle. Push all the air out of your lungs and the allow them to effortlessly fill with the air. This is important to activate the parasympathetic nervous system, which is the opposite of the "fight or flight" response that we experience when we are anxious. It's difficult to be both relaxed and anxious at the same time.

6.      Schedule "Worry Time." Allocate 15 minutes once a day at a set time specifically to worry. When you are anxious, remind yourself that you'll have those 15 minutes to process all of your concerns. This helps your anxiety stay contained and not "spill" over during your whole day. 

7.      Check Whether Your Worry is Productive or Useless. Ask yourself if there's anything specific that you can do right now to address your worry. If yes, then do it, or at least write it down into your to-do list. If not, then deem the worry to be hypothetical or unproductive, and move onto the activity that you were planning to do. 

8.      Talk to A Friend. But not just any friend. Is this a person who supports you? Or will she minimize your concerns, making you feeling even worse in the end? Decide in advance who will make you feel better and have this person on your speed-dial.

9.      Bring Yourself to the Present Moment. When you are anxious, you are really “in your head” with your mind frantically creating all kinds of catastrophic scenarios, or fruitlessly trying to figure it all out. To get back to the here-and-now, notice four things you see, three things you hear, two things you smell, and one thing you taste. Examine those things with an attention of a curious scientist that never encountered anything like that before. You can also concentrate on noticing your emotions, physical sensations in your body, and your thoughts. Continue noticing with curiosity, without judgment, and without getting engaged with your thoughts, sensations, and feelings. This little practice allows you to unhook from the thoughts about the past or future and to get in touch with the present.

10.  Learn to Deal with Anxiety Once and for All. Of course, the best way to really deal with anxiety at its core is to see a therapist who specializes in the treatment of anxiety disorders. The therapeutic approach that is most helpful for people who suffer from anxiety is a combination of Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT).

CBT uses tools such as exposure, inhibitory learning, learning to tolerate uncertainty, and postponing worry. It can also help you learn skills such as problem-solving and conflict-resolution.

ACT teaches people how to “unhook” from their anxiety, stop fighting it, and not take it so seriously. Basically, the goal of the treatment is for you to learn to turn off the “struggle switch” by disengaging from your anxiety, gradually reducing avoidance behaviors, and taking active steps toward living your best life.

Have you tried any of the tips above? Do you have other tips that help you to deal with anxiety? Share your story in the comments below!

If you enjoyed this article, follow us on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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“Mommy,” my youngest son asked looking around warily, “are there dinosaurs around?”

We were climbing up the wooden stairs after having a swim in the cold Atlantic Ocean near the village of Salema in Portugal and I was trying to balance our backpack, the picnic blanket, beach toys, and towels while holding his hand. “Who knows,” I answered absent-mindedly. My son was quiet for a few seconds and I felt his little hand tightening in mine. “But what do we do if we see one?“ “Well, we could take a picture. Or, if it’s scary and big - we run.” This answer did not put my son at ease at all. He became increasingly tense and started monitoring our surroundings very carefully.

After we finally reached the top of the long stairs and put our beach gear in the car, I noticed that my son continued scanning the environment looking pretty anxious. “What’s up with the dinosaur thing?” I asked. He pulled me back down the stairs and showed me the official-looking sign that read: “DON'T FEED THE DINOSAURS.” 

It was pretty amazing how noticing the sign in a moment changed my little boy’s perception of the environment from a beautiful calm beach to a dangerous place where scary creatures may be hiding behind the rocks and the trees. He is definitely big enough to know that there are no dinosaurs. But the sign caused him not to be so sure anymore.

Interestingly, our anxious thinking really does go back to the "dinosaur times." Our brain has a special alarm system that is meant to react to even a slightest possibility of danger - no matter how unlikely it might be. This system is crucial in times of real physical danger. But this same system can lead to a great deal of unnecessary anxiety and suffering. 

There would be a trigger - an external (something in the environment), or an internal one (a thought, a feeling, a memory, an image, or a sensation). Usually, we'd react to the trigger immediately (after all, we need the alarm for a reason), but then we'd realize that the "danger" is pretty unlikely and relax.

The problems start when we take the false alarm too seriously. If we do - it is only natural that we try to do something about it. And as soon as we give some serious consideration to that false alarm, the vicious cycle of anxiety develops. All attention is now directed on the possibility of danger. The dinosaurs seem to be hiding behind every corner. It doesn’t matter how unlikely that would be. All that matters is that it’s a possibility. Selective attention takes over and the spotlight is on the danger. The scary thoughts become "sticky" - they draw all your attention and won't go away.

The typical potential danger in their case would be:

-       What if I fail the exam?

-       Did I turn off the stove?

-       If I approach this person, they may reject me.

-       What if I get sick?

-       I feel dizzy – what if I faint?

-       Does this thought make me a bad and immoral person?

-       Negative thoughts are bad and I shouldn’t be thinking them.

To cope with the anxiety, people try to avoid the potential danger or at least seek safety or ask for reassurance. The problem is – none of these strategies are effective in the long term. Why? Because one of the main features of anxiety is the difficulty living with uncertainty. And as there’s really not much that’s certain in our lives, this constant pursuit of certainty is certain to fail (pun intended).

If you have anxiety and have asked (or Googled) for reassurance, you know how good it may feel initially. But you also know that within a few minutes you will start thinking, “But what if they are wrong? Or what if they are just trying to make me feel better? Or maybe I didn’t explain myself well…” The disappearing good feeling is short-lived and you are back to being anxious.

The more you try to avoid the “danger” or to somehow make yourself feel better, the more you learn that this is the only way to cope.

So, what can you do instead?

1.    Don’t take your thoughts so seriously. Thoughts are not facts. And they are not threats. They are just, - well, - thoughts. Ask yourself whether the recurrent thought that you may be having is bringing you closer to the life you want to live. If it does, - by all means nurture it and continue the journey toward your goals. But if it just keeps you worried and stuck, accept that the thought is there, and take the steps that you have wanted to take in spite of it.

2.     Stop avoiding the perceived danger. Yes, most of the anxious thoughts and fear are related to things that can actually happen, even though the likelihood of them happening is usually pretty low. The real question is this: what is the price that you are paying for the avoidance? How does it affect your peace of mind, relationships, productivity, health, career? Usually the avoidance does not make you safer in any significant way. It just negatively affects your life.

3.    Resist the temptation to use safety behaviours. Of course, you may want to try thinking positive thoughts, breathing deeply, or bringing a friend when you decide to face a situation that you perceive as anxiety-provoking. By all means, do it as long as you don’t avoid the situation. As you become less scared, though, try to just be in a situation without resorting to those safety behaviours. That way you will quickly learn that you can deal with the situation on your own and you are not dependent on anything or anyone to cope with it.

The only sustainable answer to anxiety is facing your scary thoughts and accepting that even though the odds are in your favour, there is still a chance (albeit a very small one) that whatever you fear may happen. If it doesn’t happen – you saved yourself from a lifetime of doubt, worry, insecurity, and fear. And if it does – you will face it and deal with it.

Meanwhile, my son came up with a new line of questioning: “Could it be that they still live in this part of the world?”

 “I thought they were extinct,” I said. “But you are right – there is a warning sign. And we may never know what it means. I think we can now go down to the beach for dinner. And if the dinosaurs approach you – try not to feed them. After all, the sign could be there for a reason.”

If you enjoyed this article, follow me on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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This is Part 1 of our series of articles on anxiety.

Anxiety is one of the most common presenting problems that patients come to our office with.

• Some people are anxious in social situations.

• Others may worry excessively about physical symptoms, thinking that they may have a heart attack or collapse.

• Another common theme is unwanted, intrusive thoughts that cause a great deal of anxiety and stress and interfere with the person's life. This is especially common in case of Obsessive Compulsive Disorder (OCD).

• Some people are fearful of specific objects or situations (such as seeing blood, riding in an elevator, taking a subway, etc.)

• And, sometimes people seem to worry about everything! They worry about the safety of their loved ones, health, work or school, and the future.

When we ask patients at the first session what they would consider a good outcome of our therapy, they usually say: I want to stop being anxious. Interestingly, it does not matter if they are old or young. Kids, teens, and adults all plead for the same thing: NOT. TO BE. ANXIOUS. PLEASE! AND LET’S MAKE IT FAST!

Then, we go ahead and disappoint them. Taking a chance that we might lose them as patients forever. We first tell them the bad news: Getting rid of anxiety is both impossible and inadvisable. 

Sometimes, we also sheepishly add, Sorry!

Then, we wait and watch. If the patient does not storm out of the office in righteous indignation, we consider the prognosis favorable and continue with the good news: Anxiety does not have to remain a problem. You don't have to continue to allow it to control your life.

And then we put on our old, dusty* CBT-therapist hat and we get to work.

The first step is:

Understanding Anxiety

First, a little disclaimer: For the sake of simplicity, I will use the words Fear and Anxiety interchangeably. But, for the word-perfect among you, they are technically not exactly the same. 

Fear is a response to an immediate, or definite threat - real or perceived.

Anxiety is a feeling we may get when contemplating a vague and uncertain potential threat, or the possibility of a threat. Basically, anxiety is the anticipation of something bad happening.

So, fear is a response to an immediate danger, and anxiety is a response to the possibility of something going wrong in the future.

But honestly, I bet if you are fearful of something, you'll be anxious about it too. And if you are anxious, you must be pretty fearful. So, one can (and likely will) lead to the other and they'll probably coincide most of the time. Moreover, fear and anxiety evoke the same physiological response.**

There are a few things that you need to know about anxiety:

1. Anxiety is normal.

We are wired to be fearful.

Did you know that our brains are wired in a way that makes it very easy for us to be scared? At the center of our brain, in the limbic system, there's an almond-shaped structure called the amygdala.*** The amygdala's job is to quickly warn us of danger.

While positive thinking is a very fashionable and sexy topic these days, let me tell you something not so sexy: We are wired to be negative.

What? How can it be? What about Oprah? And the laws of attraction?

Well, hear me out. 

When our ancestors had to decide whether the rustling in the bush meant that there was just a mouse or a tiger in the bush, they had to decide really fast. (And, hopefully, use the amygdala for help).

The negative thinkers among them likely kept thinking time after time that it must be a tiger. Those pessimists also likely kept running away for their dear life every time. If they were always wrong, they either became pretty physically fit or became the tribe clown. 

The positive thinkers, on the other hand, may have optimistically decided that it must be a mouse. I would be very interested to know if they hoped the Laws of Attraction were on their side. Unfortunately, we will never satisfy our curiosity on this matter. Why? Because, even if they were wrong just once, they never lived to tell their tale or to pass their genes to future generations.

Basically, anxiety gears us toward numerous harmless false positives and helps avoid that single devastating false negative.

My point here is that we have come by it honestly. We are probably more likely to be the surviving descendants of negative people. Sucks, I know. And a warning: Please don't share this last little factoid with your mother.

2. Anxiety Keeps Us Safe

Anxiety is helpful and adaptive. It is necessary for our survival. It protects us from dangerous situations, from doing stupid things (hopefully), and even from embarrassing ourselves (if we are lucky).

Fear activates our Sympathetic Nervous System, which triggers a "fight, flight, or freeze" response. When we are in danger, this system takes over, and we are able either to defend ourselves or escape quickly without thinking.

This is what allows us to survive. And, this is why we strongly discourage our patients' (understandable) quest for getting rid of anxiety.

3. Anxiety is Common

According to the Anxiety Disorders Association of Canada, the 12-month prevalence of any anxiety disorder is over 12% and one in four Canadians (25%) will have at least one anxiety disorder in their lifetime.

Every living organism experiences anxiety. Even a sea slug has it!

4. Anxiety is Not Dangerous

People suffering from anxiety often believe that it is dangerous and harmful. But the reality is quite the contrary. It is our ally. We just have to not let it get out of hand. 

The bottom line is that all of us living beings need anxiety for survival.

I guess this leaves us with a Love/Hate relationship with anxiety for now.

In Part Two of this article, we will talk about the main causes of anxiety.

Footnotes:

*Actually, the said hat never ever gets dusty as we use it daily.

**When people learn to ban rumination (anxiety-inducing self-talk), they may learn to experience in-the-moment fear without necessarily experiencing anxiety. But this is beyond the scope of this article.

***Really there are two such structures. And for the trivia buffs, the plural form is amygdalae. So we are all the lucky owners of two almond-shaped amygdalae that keep us super-safe!

If you enjoyed this article, follow us on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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  • Jan 22, 2019 Meet Anxiety. Anxiety: Part 1/7
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  • Dec 3, 2017 Dealing with Anxiety Components One by One. Anxiety: Part 4/7
  • Nov 12, 2017 The Discovery of Oz the Terrible. Anxiety: Part 5/7
  • Oct 8, 2017 Meet Your New Best Friend: Uncertainty. Anxiety: Part 6/7
  • Sep 10, 2017 Some More Strategies to Help You Deal With Anxiety and Worry. Anxiety: Part 7/7
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  • Nov 23, 2021 ACT for OCD: Why Fighting Intrusive Thoughts Makes OCD Worse
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  • Oct 23, 2018 Defeating the (Seemingly) Indestructible OCD Hydra: 8 Effective Tricks to Deal with New Obsessions.
  • Oct 22, 2018 OCD, is That You Again? How to Know if Your New Thought is OCD, and 6 Concrete OCD-Repelling Strategies for You to Start Practicing Right Away.
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  • Sep 4, 2018 Having Difficulty Making Decisions? This Subtle Shift in Your Perspective May Change the Way You Approach Decisions from Now On.
  • Aug 17, 2018 A Gentleman in Moscow or How to Live Life
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This is Part 2 of our series of articles on anxiety.

First, let me give you an example.

Let's say you bought a fancy new car and installed a sophisticated alarm system, that you take great pride in, to protect it from thieves. The only problem is that it goes off when the neighborhood kids play too close to it. And when your cat climbs on the hood. And when there is a gust of wind. And for no apparent reason several times at night. You get the idea.

So, what is the solution? Would you like to uninstall the alarm? Probably not, right? You love your new car and want to protect it. The alarm is not the problem. The problem is that the alarm is overly sensitive and responds to innocent triggers as if someone is trying to break into the car. Your state-of-the-art alarm just needs to be fine-tuned.

In the same way, the anxiety itself is not the problem. It only becomes a problem when you see danger where there is no real danger.

It's the perception of something neutral or ambiguous as dangerous that is keeping you on your toes. Similarly to the alarm, this perception needs to be fine-tuned.

But why, doctor? WHY?

For some reason, we all love to spend a lot of energy trying to understand why. I often find myself wondering, Why is that?

I think it stems from two faulty beliefs:

1) There must be an identifiable root cause for every problem that we experience.

2) If we find that root cause, then we will know how to resolve the problem.

(Those of you texting your ex obsessively after he broke up with you and asking, But why? Why? will know what I mean here).

I am not saying that finding the answers is always impossible or unhelpful. It's just that if you have spent a great deal of time searching and it hasn't been productive, maybe it's time to move from the ruminative question, "Why," to an action-oriented question, "How."

(To learn more about the dangerous tendency to ask "Why" excessively and how to overcome it, please click here)

Parents are especially prone to entertaining theories about what may have caused their child to be anxious (for example, moving him into a separate bed too early, bottle-feeding him, or teaching (or not teaching) him to write in cursive.) Interestingly, they often prefer spending a lot of their time in therapy confiding their fears, as opposed to rolling their sleeves and starting addressing the situation. Which, as a parent, I totally get.

Having said that, let's discuss

The Main Potential Causes of Being Overly-Anxious

(while keeping in mind that we may never really know, which is fine, as long as we address the anxiety anyway).

Both genetic factors and environment play a role in the development of anxiety disorders.

It is well-known that anxiety disorders run in families.

Environmental stressors also make their contribution.

To better understand the complex interplay between those two factors, consider this: A person genetically predisposed to anxiety may not develop an anxiety disorder if she never encounters a significant enough stressor or trauma. On the other hand, only some people who are exposed to very stressful event(s) will develop an anxiety disorder.

To make matters even more complicated, a parent who is herself anxious not only transmits her genes to her children, but often has an anxious parenting style, thus inadvertently modeling and reinforcing the anxious perception and behavior of the already vulnerable child. A parent can do it either directly (crossing to the other side of a street when encountering a dog) or indirectly (constantly warning the child of the endless dangers of the world).

Basically, your mom or dad may have taught you to worry!

In the next part, Part Three of this article, we will discuss symptoms of anxiety.

If you enjoyed this article, follow me on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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We get asked this question quite often at our OCD Clinic: “Is it possible that I have just a little bit of OCD?”

If you search the internet, you will see numerous blog posts and memes stating that it’s impossible to have a little bit of OCD. They also assert that this concept is demeaning to OCD sufferers.

But let’s put aside the semantics and the contemporary obsessional fear (pun intended) of inadvertently offending somebody and have a look at the real picture of OCD.

Here are the main diagnostic criteria for OCD:

1.    Having either obsessions, or compulsions, or both. (I have to point out that I have never actually met a person with OCD who did not have compulsions. They may just be unaware of their mental compulsions, but the compulsions are there).

2.    The obsessions or compulsions are time-consuming or cause distress or interfere with daily functioning.

As you can see, the main criteria include the question of whether obsessions or compulsions interfere with the person’s ability to function in their daily life. 

Can you have “a little bit of OCD?”

In our practice, we see people suffering from a variety of OCD symptoms. Some symptoms are severe to the point that the person is unable to leave their house, and others are so mild that the person does not meet the full DSM-5 diagnostic criteria for this disorder.

In the cases of mild OCD, the intrusive thoughts are not time-consuming in a significant way (at least, at first glance). Or maybe, even though the person is troubled by the thoughts, they do not notably impair his or her daily functioning.

As most other psychological disorders, OCD can be defined as a continuum, ranging from barely noticeable symptoms on the one end to severe impairment on the other end. “A little OCD” in everyday language may just mean that the OCD is mild.

For most psychological disorders, everybody is somewhere on the spectrum of that disorder, whether it is on the lower or the higher end of the spectrum. OCD is not an exception.

Then what’s the deal with the internet campaign against the “I’m a little OCD” expression?

This stems from the stigma associated with OCD (a neat-freak and hand-washing disorder stigma), and the “I’m a little OCD” expression is said to trivialize the OCD experience. I beg to disagree. I think that ignoring the milder manifestations of OCD and presenting OCD as a dichotomous term leads to an even further decrease in awareness of what OCD really is, and it prevents people with milder and less visible symptoms from getting treatment.

The issue of people with OCD being misdiagnosed and not getting appropriate treatment is a serious one. It is very common to see individuals who have lived their whole lives suffering from OCD without having been aware that they have OCD. Those are often people who suffer primarily from intrusive thoughts (obsessions) without visible compulsions (so-called “Pure-O”). 

Some misdiagnoses of OCD sufferers include anxiety disorders, depression, postpartum psychosis, pedophilia, delusional disorder, gender dysphoria, ADHD, and eating disorders. Instead of treating OCD, the therapists may try to treat another disorder. Or, they may address homosexuality (“helping” the client to “come out”), anger, or impulsivity.*

Sometimes, when a person with uncommon OCD symptoms that do not immediately look like OCD comes to see a doctor or a therapist, they may share tentatively that they are “a little OCD.” It may help their healthcare provider to consider the possibility of Obsessive-Compulsive Disorder. It may also lead to a referral to an OCD specialist for a thorough differential diagnosis.

We cannot expect people to use medical diagnostic criteria in their everyday language. People say that they are a little depressed, anxious, or panicky all the time. Yes, OCD is not an adjective. But this expression is an easy way to express being preoccupied with unwanted, intrusive thoughts. 

What we should focus on is not the language, but the real stigma and lack of awareness associated with OCD. As long as OCD is presented in the media as a hand-washing and organizing disorder, this debilitating condition will remain misunderstood and will continue to be perceived as trivial.

There are numerous OCD Myths that are going around and contribute to the confusion. They include confusing the everyday use of the word “obsession” with obsession as an OCD symptom, stereotypes about compulsions, and other misconceptions.

Both the general public and primary health care providers need to be educated on various, less common manifestations of OCD

Should mild OCD be treated?

The treatment of OCD, or any other disorder for that matter, comes down to the question of to which extent it interferes in the person’s life. Some people do not feel that their thoughts and rituals affect their lives in a significant way. Many of us have some minor, OCD-like thoughts, superstitions, and habits. As long as we don’t feel that they prevent us from living full, rich, and meaningful lives, there’s no need to make any major changes.

If, on the other hand, the rituals become time-consuming or prevent a person from living the life they want to live, treatment is indicated and the earlier the treatment starts, the easier it is to learn the new way of coping with OCD thoughts and urges.

There is no need to wait until the full OCD criteria are met. Sometimes, OCD can be caught early in kids and teens and addressed before the symptoms worsen. So, if a parent mentions to us in passing that the kid “is a little OCD,” we don’t get on our high horse and moralize about the semantics. We pay close attention and investigate the symptoms.

OCD treatment

The intuitive and natural way that people are compelled to deal with their symptoms is to try and avoid the disturbing thoughts that they have. They go to great lengths to reduce the anxiety by performing physical or mental compulsions, avoiding triggers, fighting the thoughts, and asking for reassurance. Alternatively, they engage with the thoughts, spending a great deal of time trying to figure them out. Unfortunately, those strategies lead to a worsening of the symptoms over time. 

The best way to deal with OCD is to seek a therapist trained in Exposure and Response Prevention (ERP) combined with Acceptance and Commitment (ACT), which are evidence-based, effective methods of treating this disorder. 

How do you feel about the expression of having a little OCD? Let us know in the comments below!

*Glazier, K., Swing, M., McGinn LK. Half of OCD cases misdiagnosed: a vignette-based survey of primary care physicians. J Clin Psychiatry, 2015 Jun; 76(6).

To learn more about anxiety and effective ways of dealing with it in the long-term, read our anxiety blog.

If you enjoyed this article, follow us on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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Photo by: Blogspot.com

As I’m stepping out of my office into the reception area to get my next patient, Michael, I can see that he is distressed.

“What’s going on?” I ask as we take our seats. 

“I’ve been practicing exposure, but somehow I’m not really scared anymore.”

Michael suffers from an obsession that he may be gay. He spends most of his time looking at pictures of men and women, checking to see whether he is attracted to them. He does endless Google searches about how to know for sure if one is gay and tries to figure out what his thoughts mean. His exposure involved getting used to the thought that he may never be completely certain whether he is gay or straight.  

“So, that’s good news, isn’t it?” I probe. “That is, if you are truly allowing yourself to embrace the uncertainty.” I pause, observing the visible discomfort in Michael’s posture and facial expression. “Is that it? Do you think you are not anxious because you are doing some subtle compulsions during the exposure?”

“No, it’s not that.” Michael looks a little embarrassed. “I don’t really think about being gay anymore. And I don’t care that much. Instead, I now constantly feel that I’m keeping things from my wife. I believe in being totally honest in our marriage. But I feel that I’m endlessly doubting what it is about my day that she must know. So, I call and text telling her about everything that’s going on in my day. And, I continue telling her in the evening too. But she is just getting more and more annoyed with me. I think… What do you think, Anna? Is it another obsession?”

I smile. Just a couple of sessions ago Michael bitterly said that he had been dealt the worst of all possible obsessions. He wished he had a fear of contamination or of being sick, since those obsessions would not have attacked the very core of who he was. “How can I live with myself like this, loving my wife and constantly feeling that I am living a double life as I may be secretly gay?” he used to say.

Now, this new obsession drives him to compulsively confess to his wife anything that happens, and he feels just as terrorized by it as by the previous one.

I repeatedly see this happen with OCD – one obsession morphs into another. A person with OCD is almost always willing to trade his or her obsession for any other one as their “obsession of the day” always seems to be the worst. That is, until they get the next obsession, at which time they would almost always prefer to have their previous one back.

This frequently happens when the patient is starting to successfully fight OCD. There is often a palpable turning point in the treatment where the person absorbs enough information and gathers enough strength and resolve to finally rebel against the OCD. After the initial spike, their OCD starts retreating…only to suddenly come back up with a counterattack in the form of a new obsession.

This always reminds me of the indestructible monster, Hydra, from Greek Mythology, who grew two more poisonous, snake-like heads each time one of its own was cut. For an OCD sufferer, the constant emergence of new obsessions that pop out can be discouraging to the point of despair. But, it’s important to keep in mind that it’s just the OCD scrambling to win its territory back. This is the point in the treatment where you can show OCD who the boss is by following these steps:

8 Ways of Coping with a New Obsession

1.    Expect it.

Having either the previous obsession return, or a new obsession emerge out-of-the-blue is a normal part of the recovery process. Expecting the disturbing thought to re-occur or morph into another intrusive thought will help you to not feel ambushed or defeated. It will also help you create a plan of how to react to it. Be on the Iookout for thoughts that keep returning. If a thought suddenly feels sticky, this is a sign that a new obsession may be starting to develop and it’s a call for action to face it as soon as possible.

2.    See it as an opportunity.

I consider it a great benefit when a new obsession emerges during treatment. It allows you, the patient, to practice all the skills that you learned in therapy with the new obsession. Done correctly, this will increase your confidence in your ability to fight OCD back and continue living a normal life regardless of which new disturbing thoughts it will come up with.

3.    Nip it in the bud.

React early! Your OCD will often try to convince you that the new obsession is not really an obsession, but rather just a reasonable concern that needs to be addressed. Don’t listen to the OCD’s lies and immediately do what you have been doing in your treatment with the old obsessions (which is basically labelling the thought as an obsession and doing absolutely nothing about it).

4.    Remember that you need to choose to continue living your life regardless of the discomfort that the new obsession brings.  

You do not have to like the discomfort (nobody does). But, it is the willingness to move forward without “fusing” with your obsession that is crucial to your recovery. Making room for unpleasant thoughts and feelings without trying to push them away or engage with them, and instead choosing to concentrate on what is important to you will keep you on the right track.

5.    Ignore the content!

As you saw in Michael’s example, and as you probably painfully learned yourself, the current obsession is usually the most painful one. The reason for that is that OCD always hits you where it hurts the most. The content of your obsessions is always the opposite of your values; the opposite of who you are. OCD attacks what’s most important to you right now.

But the fact is that the content doesn’t matter. Whether you are afraid of germs or worry that you may stab your loved one with a kitchen knife, all of those obsessions are just thoughts. They are not truths, facts, warnings, impulses, or signs. And, as such, you better treat them equally (that is, allow them to exist without taking them seriously).

It’s not the content of your obsessions that leads to suffering. It’s the process of your engagement with them –- whether it entails giving them meaning or trying to push them away — that gets you hooked.

6.    Instead of just dealing with one obsession after another, start destroying the scaffolding of OCD.

If Heracles continued to try and cut Hydra’s heads one by one, he would have gotten nowhere. Worse than that, he would have needed to deal with more and more heads until he would be defeated. To conquer the monster, Heracles had to come up with a plan that was more sophisticated than just cutting those ever reemerging heads.

If you continue chasing away every obsession by creating numerous hierarchies, allocating exposure time, and discussing each obsession in detail in therapy, the progress will be slow. The more effective strategy is to destruct OCD at its core by learning to accept uncertainty, embrace living with doubt, give up the unrealistic idea to try and control your thoughts, acknowledge that there’s a limit to your responsibility to prevent harm to yourself or others, and treat the thoughts as neutral, non-threatening events.

7.    Stop resisting!

It doesn’t matter whether you give your thoughts a lot of attention by trying to figure them out or push them away by trying to neutralize them, or if you try to replace them with “positive” thinking. In both cases you get hooked on those thoughts and become entangled with them, thus making them stickier.

What you resist, persists. So better allow the thoughts to just be. Let them come and go without trying so hard to make them go away.

8.    Change your attitude.

It is impossible to really overcome OCD without embracing a completely new attitude – one of acceptance.  By accepting that your mind may be “sticky” as you have OCD, and committing to changing your reaction to the OCD triggers, you can live your best life.  

Feeling empowered by his new understanding of OCD’s sneaky ways, as well as creating a plan of how to cope, by the end of the session Michael seems determined to fight back. But, as he is leaving the office, he hesitates.

“Just one question: this session. Should I tell my wife what we talked about in the session? You said to stop confessing. But, what if this is important to share with her? How do I know for sure if this one is an obsession?”

I make a mockingly vicious face.

Michael laughs: “Right. Sorry. It got me for a second. I guess I’ll never know for sure. Thanks, Anna. See you next week!

Has this happened to you? Have you had new obsessions pop up? How do you deal with them? Share your story in the comments below!

If you enjoyed this article, follow us on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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This is a question we get asked a lot at our OCD clinic: “How do I know if this thought is my OCD or if it is a ‘normal’ thought?” It usually happens when a person in treatment has certain familiar “regular” OCD thoughts, but then suddenly gets hit with a new, unfamiliar, unwanted intrusive thought that may or may not be OCD-related.

So even if you know that you have OCD, you may still wonder about that new thought that suddenly popped into your mind, “Is this my OCD acting up again, or is it just a regular, weird thought?”

Some examples of such thoughts include:

• What if I spilled water on the floor and an elderly lady will slip on it and die? 

• What if I get rabies from the road kill?

• What if I am that hit-and-run driver that injured a pedestrian earlier today?

• What if I stab myself with this knife?

• What if I accidentally offended God?

• What is the meaning of life?

• What if I broke the law without noticing?

• What if my thoughts are causing harm to other people?

• What if I unintentionally confess to a crime that I didn’t commit?

• What if I accidentally cheated on my partner?

• What if I sexually assaulted somebody at a party years ago, but can’t remember?

How can you know if it’s OCD, or if the thought is “normal”?

The thing is, the content of these thoughts is not specific to people with OCD. Our brain is constantly generating all kinds of creative thoughts (some more disturbing than others) and our mind chooses which thoughts to engage with. The subtle distinction between the "normal" and the "problematic" lies not in the content of the thought, but in what we decide to do about it.

Anybody can have a random, scary, nonsensical what-if thought such as, "What if I will harm my baby?" "What if I just caused a hit-and-run accident?" "What if I’ll drive my car into the oncoming traffic?"

Non-sufferers usually quickly dismiss these thoughts and continue with their day. If you have a negative thought and shrug it off without giving it much attention, you are unlikely to become obsessed with it.

In this case, your thought process usually goes, "Wow. That was one weird thought.”

But people with OCD tend to take these thoughts very seriously. Their thinking process goes like this, "Oh no! Why did I just have this thought? I must be a horrible person and a danger to others. I should try to prevent this disaster from happening. And I should double-check. And I need to understand what this thought really means."

You may find yourself engaging with the new thought by:

• Trying very hard to get rid of it.

• Trying to replace it with ‘positive’ thoughts or images.

• Attempting to figure out the exact message/meaning of this thought.

• Wondering what having such thoughts might mean about you as a person.

• Asking others for reassurance hoping to hear that the thought is not harmful.

• Attempting to neutralize the thought with a mental ritual

If you catch yourself doing any of the above, it likely means that the thought has become an “OCD-thought” and that it interferes with your life.

This over-engagement with the thought creates a never-ending loop of you trying to figure out or neutralize the thought and the thought coming back with vengeance. The more you attempt to either push away or to "understand" the thought, the "stickier" the thought becomes. 

When the thought feels uncontrollable and "sticky" and the efforts to get rid of it don't bring a lasting relief, this may be a sign that your OCD got you on the hook again.

It is especially difficult to identify the problematic “sticky” thoughts when a person has primarily obsessional (“Pure-O”) OCD

Every type of OCD is characterized by obsessions (thoughts that make a person anxious, distressed, fearful, or disgusted) and compulsions (things that the person does to reduce these uncomfortable feelings).

 The kind of OCD that primarily has mental obsessions is often called "Pure O," implying that the obsessions and compulsions are purely mental (not visible). Unfortunately, health professionals often miss the diagnosis of OCD in these cases because they can't observe the compulsions. This is tragic as the sufferers go undiagnosed and untreated for many years (sometimes they suffer silently for their entire life).

 The good news is that the "Pure O" kind of OCD is just as treatable as the other OCD categories with the same ERP approach.

Where to start when addressing the new obsession?

 The first step is to really understand how the vicious cycle of OCD develops. The more effort you put into getting rid of your thoughts, the more obsessed you are likely going to become. This includes following the popular (and uninformed) advice about trying to replace a negative thought with a positive one, to snap a rubber band on your wrist trying to stop the thought, or try to distract yourself from the thoughts by visualization, breathing, or relaxation. These tactics will force you to give these thoughts even more importance and hence, will gradually lead to more obsessing.  

In fact, trying to get rid of the thoughts reinforces “the pathway of fear” in your brain. As this pathway strengthens, the mental rituals become almost automatic.

The goal of OCD treatment is to start creating and strengthening an alternative neural pathway – the pathway of “I can have an obsession and not succumb to OCD demands.” The more you use this new neural pathway in various situations, at various times of day, with different people, and in different moods, the more you develop and fortify it.

The following are some steps to start creating this new, healthy pathway:

6 strategies for nipping the sticky thoughts in the bud:

1.    Start practicing seeing your thought just as it is – a thought. It is not a fact or a threat. 

2.    When you notice an unwanted obsessive thought, label it as such. Say to yourself: “I notice that I'm having a thought that [X is going to happen].” This is how you learn to become an observer of your thoughts instead of a willing participant in useless rumination, negotiation, and other attempts to neutralize or figure out the thought. 

3.    Allow the thought to come and go without trying to force it to go away or to figure it out.

4.    Let go of the illusion that you can control your thoughts. You may be able to do it temporarily, but it takes too much of your energy and time to sustain it in the long run.

5.    In spite of what many OCD self-help books will teach you, don’t aim to lower your anxiety. If the anxiety goes down, enjoy the good feeling. If it doesn’t – it means that you have an extra opportunity to practice building your new robust neural super-highway, so having high anxiety and, nevertheless, resisting the compulsion will benefit you even more.

6.    Reward yourself for having an OCD thought, experiencing high anxiety, and still not doing the mental ritual. This is how you know that you are on the right track. 

Bonus point: If you just had a thought that the number of strategies above (6) may bring bad luck or cause harm to you or others, deem this thought an OCD-thought and practice the strategies described here right away.

Treatment:

 It is very important to seek treatment for OCD. The only evidence-based effective treatment for OCD is Exposure with Response Prevention (ERP), which is a very specific part of Cognitive Behavior Therapy (CBT). From our experience, when ERP is combined with Acceptance and Commitment Therapy (ACT), the treatment is even more effective. This disorder does not go away on its own and the earlier you start treatment, the better. 

Summary:

To summarize, it’s not the content of the thought that determines whether it’s an OCD thought. What gives you a clue is your appraisal of the thought, your level of engagement with it, and the extent to which you take the thought seriously.

Hence, if you are not sure, I suggest you assume that the thought is an OCD thought and treat it accordingly – with lack of attention and respect. Let the thought come and go, and re-focus on connecting to the present moment while practicing the strategies described above.

Have you had new obsessions pop up in your mind, masquerading as legitimate concerns? Have you learned to identify them early. Or have you been missing them? Please share in the comments below!

If you enjoyed this article, follow us on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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What is Trichotillomania?

Trichotillomania (TTM or Trich – pronounced “trick”) is a disorder in which a person repeatedly pulls out his/her hair, which results in hair loss. This condition is diagnosed when the person is unable to decrease or stop pulling, despite the willingness to do so and feels embarrassed, ashamed, and distressed.

Most people pull hair from the head, brows, and lashes, but they can also pull from other areas of the body (underarms, pubic area, legs, and face). The area of where one pulls may vary over time.

People usually attempt to conceal the bald spots by using scarfs, wigs, or by changing the hairstyle.

Trichotillomania is a Body-Focused Repetitive Behavior (BFRB). Other examples of BFRB are Excoriation Disorder (skin picking), nail biting, cheek biting or chewing, knuckle cracking, and thumb sucking.

How does Trichotillomania develop?

Many people start pulling in childhood and early adolescence, usually during or after the onset of puberty. But sometimes it can start in the late teens or in adulthood.

Once a person starts pulling, trichotillomania usually escalates and it becomes increasingly difficult to stop this behavior. Sometimes, there is a gradual increase in pulling, and at other times there may be waxing and waning of the disorder.

This behavior could also be related to life circumstances and situational factors – stress, location, and emotional state. For example, a person may stop pulling completely during a vacation and resume pulling when she comes back home.

Who suffers from Trichotillomania?

It is estimated that about 3% of people pull their hair to the extent that the hair loss is significant and noticeable. But, it is likely that about 10% to 15% of young adults pull hair, just to a lesser extent.

Trich is considered to be more prevalent among women. In reality, however, it may be the case that it is simply easier for men to hide the bald spots on their head. They can even shave their entire head to make it less visible. This may make them less likely to seek treatment and to be diagnosed.

Trichotillomania is more common in people with Obsessive-Compulsive Disorder (OCD) and among their first-degree relatives. Other disorders that seem to co-occur with Trichotillomania are depression, anxiety, ADHD, and Tics.

Why do people pull their hair?

We used to think that people pull their hair as a reaction to tension, an impulse, or an urge and then experience relief after they pull. While this is true for many hair pullers, we now know that some of them do not experience those urges. Some people just pull automatically – without even noticing that they are pulling their hair.

Most people engage in both automatic and focused pulling. Interestingly, the majority of people initially report only the focused pulling, but after monitoring their pulling habits closely, many of them discover that they pull automatically too.

In general, people pull their hair in response to external cues (their environment), internal cues (their moods, thoughts, or physical sensations), or a combination of both.

Most common pulling triggers are:

·      Physical sensations. This includes the feeling in the skin either while pulling or after the hair is pulled, feeling the texture of the hair or the follicle, or experiencing physical discomfort.

·      Thoughts about pulling or about the specific hair, such as “This hair is too thick or too curly and must come out.”

·      Emotions, such as anxiety, anger, or tension.

·      Automatic habits. “Cruising” the scalp for the “right” hair, twirling, or stroking hair.

·      Physical environment. Pulling often occurs at specific places – in the bathroom in front of the mirror, in the office while reading, in bed before sleep, etc.

Treat the trich! How is the trich treated?

 Trichotillomania (and other BFRB) are treated using the Habit Reversal Training (HRT), Stimulus Control Procedures, and the Comprehensive Behavioral Model (ComB).

Many therapists specializing in the treatment of trichotillomania also use Acceptance and Commitment Therapy (ACT), which helps you stay motivated by encouraging you to remove the obstacles (in this case – pulling hair) in order to live the life you want according to your values.   

What to expect during the treatment?

 1.     Your therapist will conduct a comprehensive assessment of your pulling and assign self-monitoring homework using special records. This step is important to determine the pulling behavior, which includes triggers (internal or external) that precede your pulling, how you pull, and what maintains the pulling or what helps you stop.

Be prepared to examine all these elements in great detail. You will even talk about what you do with the hair after you pull. This is a very embarrassing part of the treatment to many people, but if your therapist specializes in the treatment of trichotillomania, she or he sees this as just another symptom of this disorder and nothing to be ashamed of. While some people discard the hair, others may play with it, feel it between their fingers, examine it, bite it, sort it into piles, or even eat it.

You will also likely be asked to count how many hairs you pulled in every situation that you record.

The main message here is that everyone pulls hair in a unique way.

2.     You and your therapist will carefully examine your self-monitoring records and identify which of your triggers are the most powerful. Those are the triggers that you will address in treatment.

You will also develop an awareness of your “premonitory phase” — the tension building that precedes the pulling. The therapist will help you develop a competing response to pulling (such as making a fist instead of reaching for your scalp).

3.     Your therapist will help you come up with a very specific plan to address the triggers that lead to pulling. You will go trigger-by-trigger and write down a list of strategies and materials/tools to address them.

If the treatment is provided for a child, positive reinforcement using reward charts and points is usually recommended. Importantly, the rewards are provided for using the anti-trich strategies and not for the reduced amount of hair pulled.

4.     At the final stage of the treatment, you will evaluate the effectiveness of the strategies you tried and, if needed, modify them. Then, you’ll add the next steps to your existing strategies until the pulling is significantly reduced or eliminated.

When to seek treatment for trichotillomania?

Are you experiencing the negative effects of hair pulling in any of the following ways?

- Are you changing the way you look in an undesirable way trying to conceal the bald spots?

- Are you spending a lot of time pulling instead of doing other things?

- Are you constantly feeling embarrassed?

- Are you having arguments with your family members because they beg you to stop?

- Are you avoiding going swimming or visiting a hairdresser?

- Are uncomfortable in public?

- Are you worried about your hair when it’s windy outside?

If you answered yes to any of those questions, this is time to face trich and seek treatment. Find a therapist in your area that specializes in the treatments of BFRB mentioned above (HRT and ComB) and schedule your first appointment. Please don’t let the embarrassment stand in your way!

Have you been pulling your hair (or maybe picking your skin (excoriation, dermatillomania), biting your nails, chewing your lips or cheeks, or engaging in other BFRBs)? Have you found your triggers? Have you found what helps? Share your story in the comments below!

If you enjoyed this article, follow us on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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Last weekend I was at my friend Emily’s barbecue party. After we had our full share of sausages, kebabs, and salads, and settled down at the table with the drinks, Emily said she was facing a serious dilemma and needed advice.

“They won’t allow me to work part-time,” she said. “What do I do now?”

Emily works as a psychotherapist at an agency. This is a secure (albeit boring) place of work with great vacation and sick days. But, Emily also has a small private practice that she’d like to grow. She was hoping to reduce her agency hours to part-time so that she could expand her private practice to a couple of days a week. The agency had agreed for her to do it for a while, and Emily successfully filled one day a week with private clients, but it proved impossible to continue that arrangement. Emily asked, negotiated, and pleaded with the agency, but was told she had to resume her full-time position.

Between the sips of wine, Emily talked about her predicament and sounded mildly panicked. “But what do I do with all my clients if I go back to full-time? Should I just see them after work? Then I will never be home to see my kids!”

As the conversation led toward the option of leaving the agency, the panic seemed to grow. “But then I won’t have paid sick days! And vacation. Can I afford disability insurance? And what about a mortgage? What if I need to reapply for a mortgage? And I will not have a pension!”

The thing is, Emily is a highly successful professional and is very good at what she does. Moreover, she already works at her business part time and has been doing it for years, gradually and steadily increasing the number of clients she sees every week.

But even though it was clear that she would like nothing more than to leave her unfulfilling agency job, Emily kept anticipating a catastrophe waiting for her around the corner.

“You know,” she told me, “every therapist I talk to tells me to just do it. They say they never regretted their decision. They say the only thing they regret is that they didn’t leave their jobs sooner.” I nod. Years ago, I also left a boring and unfulfilling agency job that mainly consisted of excruciatingly mind-numbing back-to-back meetings. “But,” Emily continued, “what if I am only talking to the successful people? What if this is a wrong sample of therapists that I am talking to? Maybe I should try to find therapists for whom it didn’t work out and they regretted it? They may tell me a different story.”

I knew better than to try and reassure my friend. I knew that for every argument I may come up with, there will be counter arguments about potential obstacles and dangers. And those counter arguments would definitely represent real possibilities.

Only later that day, on my way home, it finally dawned on me why it seemed like Emily and I were talking about two different things – with me being super excited for Emily finally taking such an amazing step forward in her career, and Emily feeling as if she were heading toward a disaster.

You see, we can make decisions either from an  approach perspective – moving toward our goals and desired outcomes, or from an avoidance perspective – basically, out of fear.

(If you’d like to know why we all have a natural tendency to be negatively biased and to lean toward avoidance – please read this blog post: Meet Anxiety)

Having walked this path myself, it was easy for me to see Emily’s dilemma from the approach perspective – I saw her preparing to take a leap of faith toward something that would change her life for the better. I envisioned her managing her time in the way that was best for her and her family, taking control of what she did on a daily basis, having freedom of making both short-term and long-term decisions, and setting the foundation for solid financial future. I was also already picturing us meeting for lunch and going to morning yoga classes – after all, those are the joys of being your own boss.

But Emily, as I realized after our barbecue talk, was evaluating her decision from the avoidance perspective. She was trying hard to avoid the (potential) pain of giving up the (perceived) security and facing the unknown. She was desperately looking for ways to reduce the uncertainty and to avoid pain.

When we make a decision based on avoidance – that is, out of fear, – we are consumed by doubts. We concentrate on avoiding pain at all costs. This leads to rumination, preoccupation with all kinds of possible stumbling blocks, and lack of commitment. It’s as if we attempt to walk forward while looking backwards. Try that and see how it’s almost impossible to keep your course straight.

When we make decisions from the position of approach, we excitedly look ahead. We become focused on removing the obstacles to the desirable goal. We embrace change. The journey becomes meaningful. We feel enthusiastic and empowered and, interestingly, the circumstances often almost magically align with our leap toward the welcome unknown.

This is true for most of life’s decisions and steps – big or small.

When you bring your child to a daycare for the first time, are you excited for her to have new and fun experiences, make friends, and learn to be independent? Or are you dragging your feet overcome with the numbing horror of anticipating everything that will go wrong? Both your and your child’s experience will depend, among other things, on your approach or avoidance take of this situation.

When you contemplate going on a date, are you looking forward to meeting a new person, or are you debating whether it may be a disaster?

If you feel that you are making your decisions from a position of avoidance and would like to change that, you can try the following exercise:

Try to analyze a decision that you are currently facing. Then, ask yourself the following questions:

1.    What is it that I would like to achieve here? (As opposed to, what is it that I am trying so hard to prevent from happening?)

2.    What were the other important decisions in my life that I made from an approach perspective? (Did you move out of your parents’ house to achieve independence? Did you finally apply to that college program later in life? Did you take that dream trip? Did you leave a boring job?) Do you remember how liberating it felt? How did it work for you?

3.    What will my life look like when I know that I am on my way to approaching my desired goal?

4.    What is the first step that I can take right now towards my goal?

5.    What is my next immediate step?

But wait, you may say, what if it actually doesn’t work? How can I be sure that if I take the approach path, then things will work out?

The answer is – you can’t be sure. Things may or may not work out. But, if you keep to the status quo because you make your decisions based on avoidance, you will never allow yourself a chance to move ahead. Only if you take a leap of faith and things do not work out, you can find out that you are far more resourceful and resilient than you ever knew. You will cope and you will remedy and – you know what – you will be more likely to face the next dilemma from an approach position because you will want to experience that exhilarating feeling again and you will feel more courage to pursue it. (You can learn more about coping with the fear of unknown in this article: Meet Your Best Friend: Uncertainty.)

As I was finishing writing this blog, I received a phone call from one of my associates who happily announced that she decided to rent an office at another location in addition to her current office. I said that I loved that idea and asked if she was worried about paying additional rent. “Oh no,” she said, “I am not worried at all. Now I have another location and I know the clients will come.” I just had to smile. This young woman who is just starting her career, is intuitively and happily taking the approach perspective.

If you enjoyed this article, follow me on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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"Adversity presents itself in many forms and if a man does not master his circumstances then he is bound to be mastered by them."

During the last couple of weeks, I found myself being more fully engaged in the moment. I am noticing the tastes, smells, colors, and the emotions with increased sharpness and am experiencing a deeper appreciation of life’s daily little events. All of a sudden, being mindful has become almost effortless.

Surprisingly, this seems to be related to a book I am reading. (Although the word reading does not do it justice. It would be better described as savouring, relishing, or being immersed in).

I have been a student of mindfulness for quite a few years now, studying the books of Kabat-Zinn, Thich Nhat Hanh, Eckhart Tolle, and others. I do try to combine the formal practice of mindful meditation with the way of living that emphasizes being present in the moment. I practice yoga. We do not have TV (and haven’t had for many years) and our kids don’t have any electronic devices. We hike, play board games, and try to foster a deeper connection to nature. And yet, all of this has been suddenly taken to a new level after reading the first fifty pages of this book.  

"A Gentleman in Moscow" by Amor Towles is a book in which every page is a lesson in mindfulness, even if the word mindfulness is not mentioned even once. Of course, it is also a book about strength, humility, grace, open-mindedness, and kindness. But, above all, this is a novel about mindfulness and how it allows us to live our lives to the fullest and expand our world, even when the circumstances are such that the world is closing around us.

The book is about an aristocrat, Count Alexander Rostov, who is sentenced to “house arrest” in the Metropol Hotel in Moscow a few years after the revolution. He is confined to the hotel for thirty-two years.

Instead of becoming bitter and allowing his world to shrink, the Count adapts to his new reality by remaining present and inquisitive about his world. And, his world does not shrink. The Count approaches people and events with an open mind. He is genuinely interested in others. Not only is he non-judgemental, but he has a talent to see the best in people and is curious and supportive in his interactions with them, whether it is a seamstress, a handyman, the party chairman, a spy, or a nine-year old spirited girl. He is rewarded with a life full of adventure, a close loyal group of friends, and receives love and kindness in return.  

While the Bolsheviks, “who distrust[ed] any form of hesitation or nuance,” were busy trying to eradicate all distinctions between people, stripping the Count of all his titles, and going as far as removing the labels from exquisite wine bottles so that all are equal, Count Rostov sees individuality and subtleness wherever he goes. This is how he experiences a sip of wine: 

“In a sip, it would evoke the timing of that winter’s thaw, the extent of that summer’s rain, the prevailing winds, and the frequency of clouds. Yes, a bottle of wine was the ultimate distillation of time and place; a poetic expression of individuality itself.”

Essentially, this is a book about how to live life well and to its fullest regardless of the circumstances and without ruminating on the past. As Alexander Rostov wisely observes, "…[I]magining what might happen if one's circumstances were different [is] the only sure route to madness."

The elegant writing style certainly contributed to the impact this novel had on me. Eloquent witty prose, metaphors, aphorisms, and even sophisticated alliteration for chapter names capture the reader from the very first page and enchant throughout the book.

I may never know the exact answer as to why, exactly, this book was such a catalyst for transformation, and that is OK. The important part is that there is no single road to mindfulness. This awareness may come to you after practicing daily meditation, taking a trip to another country, listening to an inspiring lecture, or looking your child in the eye. It may come suddenly, or it may gradually develop – after all “...[L]ife does not proceed by leaps and bounds. It unfolds.”

All you need to do is not to miss it and not to brush it aside. Do not undermine this fragile, subtle shift. You do that by paying attention to the moment. Being in the moment with intent and curiosity – and without judgment. Approach life like Count Alexander Rostov did in this magical novel.

If you enjoyed this article, follow me on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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A few days ago, I was talking to a friend over the phone and he noticed that I sounded tired. I did feel a little depleted after a few emotionally difficult therapy sessions.

Friend: You sound tired. What’s going on?

Me: Nothing. Had a few sessions and just finished. It was tough.

Friend: Really? I can’t imagine listening to people’s problems all day long. What do they usually talk about?

Me: All kinds of stuff. Today, somebody told me about a difficult breakup. It was very sad.

Friend: So that person goes to therapy and pays you for THAT? To talk about a breakup? He must be very sick. Oh wait, [he chuckled], - but of course he IS sick – after all, he is in therapy.

Common myths about people who see a therapist

Even though the friend meant it as a joke, this comment reflects one of the common myths about people who seek therapy. The myths I hear about the most are:

-       Therapy is for crazy people. You have to be seriously sick to go to a psychologist.

-       Therapy is for weak people. After all, if you are strong, you can resolve your problems yourself and you shouldn’t be asking for help.

-       Therapy is for people who don’t have any friends and are willing to pay somebody to listen to them.

The reality

As I am writing this post, I am reflecting on the sessions that I have with my courageous, insightful, and inspiring clients. These are individuals who want to learn, who are not afraid to admit that they have lost their way. They are strong enough to allow themselves to be vulnerable. They are willing to face their worst fears and tolerate discomfort in order to be able to live their best life.

People who come to therapy and work their way toward living life in alignment with their values, have many things in common.

-       They are willing to take risks. It’s tough to make that first step and contact a complete stranger (the therapist) with the purpose of possibly sharing your deepest secrets, embarrassing thoughts, and bitter regrets with him or her.

-       They are willing to develop an insight – an awareness of what they currently may not consciously know. This self-discovery is not easy. This is definitely another risk. It can be overwhelming and it often seems easier to maintain the status quo. Sometimes it’s terrifying to realize that you have been inadvertently contributing to your life’s problems. But, it is crucial to develop self-awareness in order to become unstuck and move on.

-       They are willing to face painful emotions (fear, anxiety, anger, disappointment, frustration, and hurt).

-       They are willing to take steps toward their goals in spite of the painful emotions.

-       They are willing to develop the capacity to become observers – of their mind, their thoughts, feelings, and behaviours, as well as the here-and-now process. They cultivate a bird’s eye view as opposed to being entangled in the tornado of events, automatic thoughts, and emotions.

-       They are willing to persevere. Those who succeed in therapy do not just embrace the concept of change when in crisis. They continue to be committed to change over a long period of time, making one small step after another, challenging the old patterns, and creating new habits. It gets frustrating. And it also gets boring. And difficult. Yet, they steadily make their way forward. 

People who actually come to therapy

Even after practicing for so many years, I continue to be in awe of my patients’ progress. They challenge me intellectually. They humble me with their wisdom. And, they inspire me to become more reflective and courageous myself. Here are some examples of clients who inspire:

- A retiree finally coming to terms with her difficult childhood.

- A business executive overcoming crippling social anxiety and making an important presentation in front of hundreds of people.

- A mom able to put her kids’ wellbeing before her debilitating overprotectiveness.

- A teenager going from feeling lost to becoming an overachiever full of feisty ambition.

- Parents determined to take a risk of not being “friends” with their teen and assuming a parental role instead.

- OCD-sufferers able to face unimaginable horrific and embarrassing thoughts and images, tolerate the dread, put the OCD into its (disgraceful) place, and make a choice to live a fulfilling life.

I could go on and on with the examples. After numerous years of practice, the examples are endless. My admiration for my patients motivates me to try and be a better person.

After all, even though I may sometimes sound tired after a long workday, I feel incredibly lucky to do what I do. And I never stop marvelling at my unbelievable privilege to accompany those brave and determined people in their journey to create their best life.

If you enjoyed this article, follow me on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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 As we are preparing for our yearly vacation, and I am excitedly telling friends and acquaintances about our plans to see the beautiful Portugal, many react with comments and questions such as:

-       Wait, but there’s nothing there for the kids to do!

-       But won’t the kids be bored there?

-       Too bad. There’s so much to see there. You probably won’t be able to go everywhere with the kids.

-       Don’t forget to upload games on your tablets – believe me you’ll need it for your sanity!

Those conversations happen every year. I try to explain that:

-       Looking at beautiful sights and exploring are prefect activities for young curious minds

-       The kids will be super excited and enthusiastic and yes, sometimes bored too – which is also totally fine.

-       We will be able to go everywhere with the kids (I mean, we are not planning to frequent seedy places too often).

-       We do not own any tablets.

But yet, I am usually met with a skeptical look.

Don’t get me wrong. I do understand how difficult it is nowadays to cater to the kids who were born in the age of fast-paced life full of immediate gratification opportunities and nonstop entertainment. Their days are often filled with extra-curricular activities, every click of the mouse on social media or a game delivers a burst of gratifying dopamine, and they expect to get a participation reward for… well, for participating.

So what can we do to allow our kids to develop an appreciation of their environment and an ability to enjoy the here-and-now? 

1.    Take a moment before you introduce a highly entertaining activity to the child.

Reflect – what is the long-term goal that you want to achieve here? It is important to separate your values from your own immediate gratification.

Sometimes, when we bring our baby – still in a stroller - to a shopping mall, buy her candy and balloons, introduce her to fast-food restaurants, and happily place her on those mall toy pony rides, the pure joy on the child’s face makes our hearts melt. We feel on top of the world. This is only natural. All we want is for our child to be happy. And we feel like such great moms and dads – even if just for a few minutes.

The reality is, however, that what makes our child squeal with delights, may not necessarily be good for him or her in the long run.

Ask yourself, what do I want my child to learn here? If your immediate feeling is in line with your long-term goals and values – then you can happily proceed. If not – you have a chance to remedy the situation before it is too late.

2.    Start early.

The older the child gets, the more difficult it becomes to take her or him away from electronics and to teach them appreciate and enjoy non-highly-stimulating activities such as going on nature walks, playing board games, and listening to classical music.

It is difficult to stop the habits that have already developed. It is way easier to prevent them from developing in the first place.

Does your baby or young child need to watch that TV program? Does she or he really need to watch TV at all?

Are you sure you want to introduce them to electronic games? Or can you introduce them to  board games that you can all enjoy as a family?

Do you cook a separate meal for a child, or do you cook a meal for the whole family, so that the child can gradually be introduced to a wide variety of foods?

Are you sure you really need to spend your weekends at an amusement park?

The earlier you start, the more natural and straightforward the process will be.

3.    Don’t parent out of fear.

When I give those suggestions (and many other suggestions on different topics) to parents that come to my sessions, the frequent response is fear. Fear of the child being bored. Fear of tantrums. Fear of feeling bad about oneself as a parent. Fear of judgement. Fear of making a mistake.

Whatever you do – parenting out of fear does not work. Make a decision about what you consider to be in your child’s best interest right now, and stick to it. (And give yourself permission to reconsider – as long as it’s not out of fear).

4.    Make it fun

Kids are very curious by nature and are usually happy to learn about new stuff (that is, if they are not glued to a screen, in which case, unfortunately, you’ve got a tough competition).

Travelling is such an amazing educational opportunity – whether it’s travelling to another country, camping, or a hike at a beautiful location an hour away from home.

Talk about your upcoming trip beforehand:

-       Let them study and draw the maps

-       Take lots of library books and let the child read to prepare

-       Explore history, architecture, culture, and cuisine.

-       Watch videos of the country or city you will be visiting

-       Practice words and phrases in a different language if you are traveling abroad.   

-       Hold trivia contests about your destination at dinner time.

-       Assign the child a task that she or he will be responsible for during the trip. An older kid could be the official family photographer. A younger kid may be responsible for making sure there is always enough bottled water to carry along. Every kid can carry his or her own backpack with snacks, drinks, and notes that they prepared for the trip.

-       Another idea is to get the child to be an expert in one field (learning the words and phrases in foreign language; reading up on medieval hill towns or other interesting facts; identifying the names and ingredients of the country’s cuisine, etc.)

-       Buy cute little notebooks so that kids can journal daily during the trip.

5.    It’s not too late

Even if your child is not very enthusiastic because of his or her temperament or because he or she is already used to highly-stimulating activities, you can try and gradually start involving him or her in mindful day-to-day activities.

It is very important to identify what interests your child, and to start from the things that he or she is likely to enjoy the most. Following are some ideas:

-       Cooking or baking together

-       Gardening

-       Short walks (and if you engage in conversation that is interesting to your child and the walk becomes longer – more power to you)

-       Playing a board game

-       Developing an interest or a hobby together and reading up on it and discussing it

As we are preparing for our trip, our kids spend their evenings reading about Ferdinand Magellan, Vasco da Gama, and Henry the Explorer. They identify Portugal districts and their main towns. They anticipate trying Portugese foods, and giggle nervously at the thought of trying snails and barnacles . They learn basic Portugese phrases and put together a kit of activities to take to long car rides (magnetic chess, word search, and journals).

These preparations are not less important than the trips themselves. They teach the kids patience, open-mindedness, and cooperation. They create memories and sense of connectedness that will last for the life-time. 

Do you have a story about your experience of travelling with kids? Any tips for other parents? Share it in the comments below!

If you enjoyed this article, follow us on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

Why may it be unhealthy to ask Why all the time?

Do you frequently ask yourself:

-       Why did this happen to me?

-       Why do those things always happen to me?

-       What’s wrong with me?

-       Why couldn’t I have handled things better?

-       Why do I always react this way?

-       What does this mean about me?

Questions, such as, “Why me?” or “What’s wrong with me?” and replaying the problem or a situation over and over in your head, may be a sign that you have a tendency to ruminate. 

What is rumination?

Rumination is repetitive “over-thinking” or dwelling on a problem or on a negative feeling. We may brood on what might have caused the problem, ponder on our predisposition to encounter obstacles, or obsess about the unfairness of the world.

Rumination is the tendency to replay negative experiences over and over again in our minds.

Rumination actually originates from the Latin word rūminātio - chewing the cud. Yes, that is what the cows do – chew and re-chew and re-chew their cud.

But what is the problem with asking this little innocent question “Why?” over and over again? Isn’t it good to get to the bottom of the issue? Maybe, just maybe, if we ponder on it a little more, we will find a solution. Or maybe we will learn a valuable lesson that will allow us to act differently in the future. Or we will finally understand the root of our problem. Or will figure out something important that we might have missed.

Unfortunately, rumination often masquerades as self-reflection and problem-solving. But no matter how long we continue to ruminate, we will not find the solution. Rumination does not help us to move on. It keeps us stuck. Instead of helping us to have clarity, it just makes us feel worse.

Moreover, when people ruminate while they are in a negative mood, they interpret life situations and events more negatively, remember more negative things that happened to them, and feel more hopeless about their future and more helpless to change it. Rumination leads to passivity, disempowerment, and anger.

As if it’s not bad enough, research shows that excessive rumination is related to and may increase depression, anxiety disorders (especially social anxiety and Generalized anxiety Disorder (GAD)), OCD, illness anxiety, PTSD, eating disorders, and substance abuse.

What is the difference between rumination and problem-solving?

Of course, reflecting on a problem with the purpose of taking active steps toward improving the situation is an important step in achieving our goals.

Rumination, however, means passively dwelling on a problem for too long. It usually focuses on the abstract aspects of the problem, not on the concrete steps toward a solution. If anything, this endless dwelling often stands in the way of finding a solution or making a change. Therefore, while problem-solving may move us closer to our goal, rumination keeps us where we are.

When you approach the problem in a very concrete and specific way and brainstorm the practical steps to improve it or approach a similar situation differently in the future, you are probably problem-solving.

If you think about the same situation in an abstract way, generalize it, and ask a lot of Why? questions – you are ruminating.

Why do people ruminate?

Rumination often feels as if we are resolving a problem. It may, therefore, make us feel productive for a little while. It also makes us feel that if we ruminate enough, we will finally understand what happened and why, we will make sense of everything, and will be able to avoid these mistakes in the future. Or it can actually replace taking an action – thus, bringing short-term relief as we feel we can postpone any action or decision-making.

Recent research has focused on conceptualizing rumination as a habit (a pretty unhelpful habit, that is). Seeing it as a habit helps explain why it is so difficult to stop ruminating and also provides strategies to overcoming or diminishing it.

When we tend to ruminate every time we are in a bad mood, we develop a connection between the bad mood and rumination, and in time, we just can’t help it – when our mood worsens, we start ruminating. And when do we tend to have a dampened mood? Usually, it is when for one reason or another we are unable to make progress toward our goals. An example of a goal may be getting a job, developing a closer relationship, succeeding at school, improving our financial situation, etc.

Basically, if each time we feel bad because we don’t progress toward our goal, we turn to rumination, we develop a passive ruminative stance that becomes deeply ingrained in our thinking. It becomes automatic and is very difficult to change.

To summarize:

Sad Mood + Repetitive Abstract Negative Thinking + Reduced Active Coping = Rumination Habit

How to overcome or reduce rumination?

First of all, you need to identify whether it’s a rumination, a self-reflection, or an attempt to problem-solve.

Do you focus on the concrete changeable aspects of the situation or on the abstract questions?

Do you focus on the specific doable steps to remedy the problem or do you dwell on how bad things are?

Second, examine the benefits and costs of rumination. How is rumination helping you? Do you feel that it helps you be more prepared for worst-case scenarios? Does it distract you from starting to take action on difficult things? Does it provide a sense of control over your life? And what has rumination been taking away from you? Are you less present and engaged in your life? Do you waste a lot of time ruminating? Do you live in a permanent state of doom and gloom?

Remember how we said earlier that the habit of rumination develops when you routinely turn to rumination each time you feel bad? Conversely, if you use other strategies (such as active problem-solving, fun activities, or other distractions) as a response to your negative mood, - you are effectively replacing your rumination habit with other (more productive) habits. Even though rumination seems involuntary, it’s actually a cognitive process that we are able to change by practicing doing something else instead of ruminating.

Specific steps to change the rumination habit

1.    Become a detective.

If rumination has become a habit, it has also become a pretty automatic response to a bad mood. It may seem that it is coming out of nowhere. But it isn’t.

You need to start monitoring very closely and to identify the situations and conditions that tend to trigger your rumination:

- Maybe it's a particular place in your home or at work, a time of the day (for example, first thing in the morning, or before bed).

- Does it happen after a social interaction?

- What are the first physical signs of an emotion that lead to rumination (could it be the feeling of the tears coming up, or increased heart rate, or tightening in your chest?)

- Or are there specific thoughts that usually precede your rumination?

Each time you catch yourself ruminating, stop and ask: what had happened right before I started ruminating? Where was I? What was I thinking? What was I feeling? What were the sensations in my body?

2.    Practice non-engagement.

This is not just passively doing nothing. Non-engagement means actively making a choice to not engage in ruminating. You practice consciously shifting your attention to another topic or activity even though you are still aware of the problem.

3. Come up with alternative strategies that will replace the rumination.

Those strategies have to be incompatible with rumination, and they also need to be rewarding.

Some examples of the strategies are:

-       Active problem solving (thinking of concrete steps to take; developing a plan)

-       Physical exercise

-       Listening to upbeat music

-       Going for a walk

-       Dancing

-       Calling a friend (and not talking about the problem)

-       Relaxation

-       When you catch yourself asking “Why” questions, try to modify those questions into a more practical “How?” How exactly did it happen? How can I make it better?

4.    Start working on breaking the connection between the triggering situations or conditions and the ruminative response. 

This is done by replacing rumination with the strategies that you identified as helpful and incompatible with rumination.

It goes like this: you plan ahead and have a list of alternative strategies ready for the situations where you usually ruminate. When you find yourself in one of those situations (or feel a negative emotion), you immediately implement at least one alternative strategy.

Remember: you are working on breaking a bad habit. It is very important that you consistently practice the strategies that you have chosen as a response to your negative mood or to the situations that you recognize as leading to rumination.

5.    The goal is to form a new habit.

As you consistently respond to the identified triggers with the newly chosen activity, - you eventually start doing it automatically.

6.    Practice, practice, practice.

Be on a constant lookout for your cues/triggers. Use every opportunity and every cue to practice the newly chosen activities as a new response. Your goal is to do it as many times a day as possible. Remember - rumination is a habit and habits are difficult to break; therefore, you need to practice a lot!

7.    As an advanced bonus strategy, when you progress, try re-creating the cues for rumination on purpose so that you can practice immediately connecting them to the new activity.

You can re-create a sad or angry mood by recalling a sad or aggravating event, playing sad music, or purposefully putting yourself in a situation/place that you know will lead to a negative emotional state.  I know it sounds counterintuitive but think of it as a wonderful opportunity to regain control of your reaction to those situations (that is, not ruminate).

8.    Don’t give up!

You know it takes time to change a habit. But it is well worth the effort to finally start actively addressing the problems instead of passively dwelling on them.

89.    Seek professional help.

Long-standing habits are very hard to break. If you feel that rumination is interfering with your life or if you are feeling anxious and/or depressed, it may be time to seek psychotherapy.

There are various strategies that your therapist may be using to help you overcome rumination. A therapist specializing in Cognitive Behavioral Therapy (CBT) will conduct a functional analysis of ruminative instances, identifying antecedents, behavior, and consequences that are involved in keeping the habit going. She will then help you find responses that are incompatible with rumination and incorporate them into your daily life.

References:

Harvey, A. G., Watkins, E., Mansell, W., & Shafran, R. (2004). Cognitive behavioral processes across psychological disorders. Oxford, UK: Oxford University Press.

Treynor, W., Gonzalez, R. & Nolen-Hoeksema, S. Cognitive Therapy and Research (2003) 27: 247. Ruminative Responses Scale.

Watkins ER, Nolen-Hoeksema S. A habit-goal framework of depressive rumination. J Abnorm Psychol 2014;123:24-34.

 If you enjoyed this article, follow me on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

School is out for the year and children everywhere have taken a collective sigh of relief.  Admittedly, even teachers and principals.  But like winter in Canada, school is just around the corner; possibly the most wonderful time of year for parents and the most dreaded for students.  However, for some students, getting up and going to school may be harder than most. 

Parents, have you tried waking up your child in the morning only to be greeted by the words, “I’m not going to school today”?  Join the club!  As parents, we know kids refusing to go to school is par for the course.  We expect it.  After all, we probably did it ourselves.  So it’s normal, right?  Well, what if all of a sudden, that sober statement turns into a deep guttural, heart-wrenching cry that reverberates throughout the whole house as your child yells and screams that s/he does not want to go to school!  This is no longer an act of defiance.  This is something far greater. 

As you try to pacify your child, nothing seems to work.  No amount of promises, sweet talk, nor even taking a firm stance dissuades them from their position.  Scared and concerned, you retreat from your child’s room wondering:  Where did my happy-go-lucky child disappear to?  Did something happen at school?  Is my child being bullied?  Your mind races with scenarios to explain this other-worldly presence that is now inhabiting your child’s bedroom.

What I have just described is a child experiencing anxiety.  Yes, you heard me - anxiety.  Kids experience anxiety, and data confirm that anxiety is on the rise in children and adolescents. 

Anxiety occurs when our amygdala, the part of the brain that’s responsible for the flight or fight response, becomes hijacked by our brain’s effort to protect us.  This served us a well when we were being chased by wild animals, but now, the triggers often tend to be psychological in nature, such as feelings of uncertainty, embarrassment, or separation.  With neurochemicals surging through the body, the mind and body are primed to tackle the threat - muscles are taut and the body is on fire ready to fight or flee.  Thus, the anxious screaming child who does not want to go to school will resist at all costs.

Some of you may be reading this and feel relief that you can now identify what you have personally witnessed.  Again, recognize that this is anxiety and not simply “bad behaviour”.  People suffering from anxiety participate in avoidance strategies that ironically fuel their anxiety even more.  The child who does not want to go to school and is given permission to stay home will become more vehement about not returning to school the next day because the fear of humiliation or embarrassment has grown to a new level.  On the other hand, forcing your child to go to school may also cause problems.  But what do you do? 

1.     It is important that you as a parent become well versed in anxiety.  There are many books that have been written on anxiety and its impact on children.  As you educate yourself, you will need to educate your child.  Your child needs to understand what is happening at a level that matches their cognitive development.

2.     One technique is to distance the anxiety from the child.  The anxiety is NOT your child.  Often, counsellors will name the anxiety, “Your anxiety brain,” or “Mr. Bossy Pants,” or “Mrs. Fuddle Duddle.”  Whatever works and connects with your child.  Let him/her choose the name.

3.     Your child will need to learn to challenge his/her “anxiety brain” with questions like “How do you know that by going to school something bad will happen?” or a direct confrontation like, “Show me the facts!”  Sometimes a flat out denial of anxiety’s authority is necessary: “The last ‘x’ amount of years of going to school nothing terribly bad has happened, so I don’t believe you!”

4.     Your child will need to establish and manage a new relationship with worry.  The worry in itself isn’t bad; however, when it takes over all cognitive processes, then we need to do something about it.  Your child will need to determine when it’s time to let worry in or not, how often worry comes around, and how long it will stay while visiting.

5.     Parents, this one is specifically for you.  Get your school involved!  That’s right!  Your child’s teachers and the administration team (principal/vice-principal) should know that your child is battling anxiety.  Your school should be there to support you.  As the saying goes, it takes a village to raise a child.  I can you tell you from personal experience that my son has moments where he needs to remove himself from class.  He walks out of class and right down the hallway into the office where a special journal is laid aside for him to write down his worrisome thoughts.  All his teachers are in on it and no one bats an eye when he walks into the office.  It’s the epitome of support and it allows my son to make it through those school days when the going gets tough.

Witnessing anxiety in your child can be a frightening experience.  Anxiety doesn’t have to be a debilitating condition.  It is a good idea to have your child talk to a therapist to help them manage their “worry brain”.  With summer out, now is a good time to talk.  Give your child the confidence and the tools they need to face the new school year head on!

Dimitri-Kaklamanos, MACP, Turning Point Psychological Services

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The spring is finally here! When the sun is shining, and everything is starting to bloom, we naturally feel more energy. This is a great time to do something wonderful for our children and ourselves.

Spring is the best time to start gardening. This simple activity has vast physical and emotional benefits. Additionally, it is tremendously important for our electronics-dependent children to venture outside and to connect with nature while disconnecting from the constant stream of information. 

What is the best age to involve the child in gardening?

The great thing about gardening is that even young preschoolers can get very involved - they can choose the plants, dig, water, weed, harvest, and engage in food preparation.

A step-by-step guide to introducing your child to gardening

It is important to get the child interested in this little project so that it doesn't feel like a chore.

1.  Browse together through pictures of vegetables and berries that grow in your area. Ask your child which plants will be the most fun to grow.

For Southern Ontario it's easy to grow:

• Tomatoes

• Cucumbers

• Kale

• Swiss Chard (the rainbow chard is easy to grow and looks gorgeous in the garden)

• Peas

• Squash (super easy to grow even from a seed)

• Strawberries (colorful, easy to grow, yummy - should I say more?)

You can also plant some herbs:

• Rosemary

• Thyme

• Dill

• Mint (but be careful as it will spread over your garden - keep it contained)

2. Help your child research the ways to care for the plants she selected. Of course, it is the easiest to ask Google. A more mindful way is to take a book from your local library and to spend a few evenings reading and discussing.

3. Plan the layout of your little garden together. Encourage your child to draw a picture and to allocate places for the plants that she has chosen.

4. Now the fun part - going together to a nursery and selecting the plants.

5. Plant according to the picture that you created.

6. Voila - enjoy your garden! 

Tips:

- Make it fun! I know I already said that, but this is probably the one most important part of this all. The goal is not to make the garden perfect. It is to instil the love of and connection to nature in your young child and to encourage responsibility and mindfulness. 

- Start Small. This is not the time to be overly ambitious. The goal is not to mass-produce. What we are trying to do is to teach the child patience, nurturing, and mindfulness of this magical process. 

- Keep it simple. Growing vegetables from seeds and seeing the little seedlings emerge is great fun, but it has its own challenges. For some plants, it's important to start planting indoors and later move the transplants into the garden. 
If you are new to gardening, it is easier to just purchase transplants. 

- Don't have a garden? No problem. Research the plants that can thrive on a balcony. Another option is growing herbs and plants indoors.Or look for a community garden in your area. But if you have an option to plant outdoors - this is much more fun and gets the kid out of the house for a while - even if it is to a balcony. 

Emotional benefits of gardening

- Stress and anxiety reduction. That's one significant benefit. Kids often spend their whole days at school or daycare, attend extra-curricular activities, and are constantly bombarded with images from TV and other screens. They deserve a break! Spending time outside in nature is super relaxing. The connection to earth is very special. It promotes quiet focus and contentedness. 

- Promoting creativity and imagination. There is a great deal of dreaming, exploration, planning, brainstorming, and problem-solving involved. 

- It teaches your child responsibility. He has to remember to water the plants consistently, check on them, remove harmful bugs (this is also the best way to deal with phobias (fears) of insects), and to weed the plants regularly. 

- The child will need a lot of patience to tend to the plants and to await the fruit. It is more important than ever to develop patience in this day and age of instant gratification. 

- The sense of accomplishment. What a great way to boost self-esteem! 

- Shy and anxious kids will have a conversation-starter when a friend comes over for a play-date. 

- Parents often get stuck in trying to establish a connection with their child solely through conversations. But so often the kids' response to the question, "How was your day?" is a laconic, "Good." Engaging in an activity together facilitates effortless connection through a common interest and working together toward a common purpose. It also creates an opening for further discussions and other activities - taking pictures of the plants at various stages, creating a photo album, browsing cookbooks, cooking - the possibilities are endless. 

Physical benefits of gardening

- As any gardener will tell you - gardening is a great physical exercise. All this bending, planting, pulling, digging, carrying, tilling, raking, and watering is such an enjoyable way to get your little one to exercise! 

- Gardening has been shown to reduce cortisol (the stress hormone) levels. Research shows that gardeners had lower cortisol levels than people who tried to relax by reading. 

- Gardening improves strength, flexibility, balance, and sensory perception. 

- Spending time outdoors allows your child to breathe the fresh air and to benefit from Vitamin D, which is produced when his skin is exposed to sunlight. 

- Through gardening, your child will be exposed to highly beneficial microorganisms in the soil (Mycobacterium vaccae). Amazingly, it helps stimulate serotonin production, leading to a happier and more relaxed feeling. Talk about make-you-feel-happy little microbe. 

- Better nutrition. What better way to get picky eaters to have their vegetables than having them grow their veggies and participate in food preparation! 

Sensory benefits of gardening

Gardening involves all the senses! Touching various textures, smelling, listening to the outdoor sounds, looking carefully while inspecting the plants, discussing the progress, and, of course, tasting the yummy outcomes of their hard work - those are all wonderful and important sensory experiences! 

And one more bonus benefit: A happier mom or dad. You are also reaping all those wonderful benefits, thus, providing your precious child with a happier parent! 

By teaching your child to interact and connect with the natural world, we are giving her a gift of emotional fulfilment and improved psychological and physical heath. Try it this spring!

If you enjoyed this article, follow me on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

What is Affect Labelling?

When experiencing a negative emotion, we often try to ignore it, pretend it's not there, or distract ourselves. Unfortunately, it requires a lot of energy and does not always work. A surprisingly effective strategy to deal with a negative emotion is to actually stay with the emotion, identify it, and name it in your mind or say it out loud. Psychologists call it Affect Labelling (naming your feelings).

Research

This technique may sound simplistic, but it is actually based on solid neuroscience research. Interestingly, some of the research was done on arachnophobiacs (folks that are terrified of spiders). Those courageous research subjects had to get very close to a tarantula, while one group had to label their scary feelings (“I feel anxious the disgusting tarantula will jump on me”), another group tried to engage in positive self-talk (“Looking at the little spider is not dangerous for me”), and two other groups either said irrelevant distracting things (“There is a TV in my home”) or did not say anything.

Which group had the least fear? 

If you guessed that it was the first group – you guessed right! People who labelled their feeling had a reduction of fear. Moreover, when they were retested a week later, their fear was the lowest of all groups. Additionally, then more words they used to represent their negative emotions (such as, I’m nervous, afraid, scared panicky), the more their fear reduced.

These findings were replicated in people with social anxiety (a fear of public speaking).

An fMRI (functional magnetic resonance imaging) study of affect labelling confirmed those results. Here it gets a tiny bit technical, so please bear with me, or feel free to skip to the next section.

In the center of our brain, there is an area called the amygdala, which reacts to fear and triggers a fight/flight response. It is activated when we experience negative emotions. When we label (name) those emotions, however, - the brain activity in the amygdala diminishes. Additionally, affect labelling leads to an increase in the activity in another brain region – ventrolateral prefrontal cortex. So we learn to recognize and regulate the emotions instead of being reactive to them.

This is consistent with unhooking (defusion) - a technique often used in Acceptance and Commitment Therapy (ACT). A simple way to unhook (de-fuse) from a painful emotion is to notice and name it: “Here is my anxiety,” “I am noticing a feeling of sadness,“ “I am noticing that my heart is racing.“ This simple intervention diminishes the power that our feelings, emotions, and thoughts have over us.

What Does That Mean to You?

Those results indicate that by labelling our negative feelings we are calming the emotional center of the brain so that it becomes less reactive. This gives us an opportunity to step back and assess the situation better and respond to it in a more psychologically flexible way. And the most important thing – by giving a name to the emotion, we instantly become less trapped by it.

So the bottom line is – putting feelings into words quickly and effectively diminishes their negative impact. Name them to tame them!

Practical Tips

Try it! Next time you feel a negative emotion:

• Stay with it

• Identify it

• Clearly name it

Again, you don't have to say it out loud. Naming the emotion in your mind will work just as well!

If you want to make this technique even more effective, you may put it this way: I am noticing that I am having the thought that I am anxious. This puts even more distance between you and the emotional impact of the thought and allows you to take a step back and to not be consumed by the emotion.

Some people have difficulty labelling an emotion. To help you out, here goes a list of some emotions that tend to trap us: anxiety, anger, fear, shame, sadness, frustration, disappointment.

Other (albeit more time consuming) effective strategies that employ a similar rationale are:

• Meditation

• Journaling

• Talking with friends about your feelings

• Expanding your emotional vocabulary - learning to identify and name more subtle emotions. For example, when you feel angry, you may feel annoyed, irritated, furious, offended, impatient, frustrated, etc.

When we engage in those activities, we learn to become observers of our emotions, as opposed to being immersed in them. We become more effective in dealing with the emotions.

If you enjoyed this article, follow me on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

This is Part 3 of our series of articles on anxiety.

There are three main ingredients to anxiety:

1. Thoughts

When we feel threatened, our attention is focused on the perceived threat. (Perceived is the key word - remember the overly sensitive car alarm? The threat can be real or nonexistent. As long as we perceive it as dangerous, we are on high alert).

Our perception of a situation mostly depends on what we say to ourselves about it. Anxiety-related perceptions and thoughts revolve around the themes of danger (physical, mental, or social), threat, or vulnerability.

Examples of anxiety-producing thoughts are:

• Everybody will think I'm stupid

• Something is very wrong with my body

• What if I make a fool of myself?

• Dogs are dangerous and will attack and bite

• What if something happens to my child?

• I will fail this test

• What if my friend rejects me?

Our brain interprets these thoughts as a signal to prepare for danger. Since we are preoccupied with focusing on survival, we have difficulty concentrating on anything else.

Students that are anxious about academic performance have difficulty focusing on the exam questions. People that are anxious about social situations can't follow a conversation. And people with panic disorder are so hyper-aware of their physical symptoms that they can hardly attend to anything else.

Speaking of physical symptoms. Those, by themselves, are another component of anxiety:

2. Physical Sensations

Remember the Fight/Flight Response (the Sympathetic Nervous System) from Part I of this article? When it gets activated, it causes your adrenal glands to release two hormones - adrenaline and noradrenaline. This leads your body to respond in several ways:

• Increased heart rate. This happens because your heart and vital organs need more oxygen and better blood supply.

• Rapid breathing (hyperventilation) - you need to breathe much faster so that more oxygen is delivered to major organs.

• Feeling dizzy or lightheaded. This is the natural response to hyperventilation, as there's suddenly too much of the good thing (oxygen) in the body. Another reason is that most of the oxygen goes toward the muscles, so there's a little less left for your brain, which results in a feeling of dizziness.

• Tightness and pain in the chest as all of your muscles tense in preparation for danger. Again, the blood flows away from the peripheral areas to the major muscle groups (e.g., from our fingers to our arms).

• Upset stomach or nausea (especially in kids, tummy aches are very common). The time of danger is not the time for leisurely digesting your dinner. The energy is needed for other parts of the body.

• Sweating. To cool your body and to make it more slippery so that it's more difficult to grab you in case of a fight. (Isn't that cool?)

• Numbness or tingling in fingers and toes because of the blood flow away from these areas.

• Choking sensation. Again, muscle tension.

• Feeling unreal. This relates to your pupils dilating so that you can see better, which may lead to a strange feeling of unreality. This may also be related to that diminished oxygen supply to the brain.

As unpleasant and dangerous as those symptoms may be, they actually represent the wonderful survival system of your body. So, when patients with anxiety describe some of these symptoms to us, we usually congratulate them on being healthy!

3. Behaviours

When faced with danger, our natural response is to escape. After escaping, we usually feel relieved. In the future, we try to avoid the situation that we perceived as dangerous. We also try to make ourselves as safe as possible when we can't escape the situation.

All of those components of anxiety (Thoughts, Physical Sensations, and Behaviours) are interconnected:

• The more of those anxious thoughts we have, the more severe our physical reactions will be, and the higher our desire to escape and be safe will be.

• The more physical reactions we experience, the more anxiety-related thoughts we will have, and the more we will try to avoid the situation.

• And, the more we attempt to escape or be safe, the more we will attribute dangerousness to the situation (via our thoughts), and the more severe our physical responses will become.

So, all three components of anxiety create a vicious cycle, with each element influencing the other two.

But here's the good news: In a similar way, if we address any one of the anxiety components, the other two will also start diminishing.

How do we do it? In Part 4 of this article, we will review dealing with each of the anxiety components. But first,

A few words about what DOES NOT help:

Well-meaning friends and family members (as well as numerous positive-thinking-oriented self-help books) tend to provide us with advice and "useful" tips such as:

• Don't worry, everything will be okay.

• Think positively.

• Just try to be calm.

• If you think about negative stuff, bad things are more likely to happen.

• You are strong!

• Believe in yourself!

• I also worry sometimes, but then I think about the good things and my worries go away.

• Relax!

If you have already tried those, you know that they don't work. And if you are at the stage where you are considering trying them, let me save you time and spare you from disappointment. Instead, please read on. In Part 4 you will learn some evidence-based CBT strategies to deal with anxiety.

If you enjoyed this article, follow me on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

Related Posts

This is Part 4 of our series of articles on anxiety.

In the previous article, Anxiety, Part 3, we talked about the three components of anxiety: Thoughts, physical sensations, and behaviours.

We also learned that each component affects the other two.

In this section, we'll see how we can deal with each of those components.

1. Overcoming Anxious Thinking

The first step is to actually start being aware of your thinking. Some people find it easy to do, while others initially struggle to identify their thoughts.

Start paying attention to the thoughts that cross your mind in situations that make you anxious. Whenever possible, record those thoughts.

Sometimes, it's easier to start with situations where you are only mildly anxious, and gradually work up to identifying the thoughts in more anxiety-producing situations.

After you have a good understanding of the anxious thoughts that you repeatedly experience, try to examine how true they are.

Ask yourself these questions with regard to your anxious thoughts:

• What is the evidence that this thought is true?

• What is the evidence that this thought is not true?

• Have you had this thought before? How often?

• What is the likelihood of whatever you worry about happening in the future?

• Is it a guess or a fact?

• Is it a hassle or a horror?

• What is the worst possible outcome?

• What is the best outcome?

• What is the most likely outcome?

• What would my non-anxious friend say about it?

Try to separate the evidence and the reality from the way you feel. Sometimes, we make an error believing that if we have a bad feeling, it means that things will be bad.

It may be useful to have a friend help you evaluate the evidence for and against your thought.

After the thorough evaluation of the thought, write down an alternative realistic statement that better reflects the reality. This statement does not have to be positive; it just has to be based on facts.

2. Addressing Anxiety-Induced Physical Sensations

Two techniques that best address the physical sensations of anxiety are:

• Progressive Muscle Tension and Relaxation

• Abdominal Breathing

It is important to practice those techniques at times when you are not anxious. Often, when people rely on these techniques to get rid of anxiety, they start perceiving anxiety as dangerous and something they can handle.

Schedule about 15 minutes a couple of times a day to do those exercises. For example, in the morning and before bed.

Progressive Muscle Tension and Relaxation

This is a special way of tensing and relaxing your muscles.

Why can't we just relax the muscles? Why is it necessary to tense them first?

Sometimes, if we try to relax the muscles without tensing them first, it is difficult to achieve real relaxation. When stressed, we tend to forget how relaxed muscles feel! Therefore, start from one group of muscles and tense them for about five seconds. Then, release and relax for about fifteen seconds.

• For example, start with your right hand. Make a fist and hold for five seconds. Release for fifteen seconds.

• Now, tense the entire right arm for 5 seconds. Release for fifteen seconds.

• Then, repeat on the left side.

• The same with the foot, lower leg, upper leg, and then the entire leg.

• Repeat on the other side.

• After, tense and relax the buttocks, stomach, chest, shoulders, neck, mouth, eyes, and face.

Some important tips:

• Only practice this in a non-anxious state.

• Each time you release the muscles and relax, concentrate on the difference between the tense state and the relaxed state. This is very important and will eventually help you quickly achieve a relaxed state, as you will know the exact feeling of it.

• As you progress, you can tense and relax both arms, then both legs, then the torso, and then the face.

• As you progress even further, you will be able to just relax without tensing the muscle first. But don't rush there. It will take a lot of practice first.

• A benefit of this exercise is that you'll start to notice the first signs of tension as you go about your day, which will allow you to address it early on.

Abdominal Breathing

To practice Abdominal Breathing, lie down on your back and put one hand on the abdomen and another on your chest. Try to breathe in a way where the air travels all the way down toward your tummy. Your goal is for the hand on your abdomen to move up and down, and the hand on your chest remain still.

Now, try to inhale to a count of four, then hold your breath for about two counts, and then exhale to a count of four. Then, pause for another count of two.

As you practice, you can work toward making your exhalation longer than the inhalation:

• Inhale for a count of four

• Hold your breath for a count of two

• Exhale for a count of six

• Pause for a count of two

Please note that the goal of those techniques is not to avoid being anxious!

Remember, anxiety is our friend and we don't want to get rid of it. We also don't want to see it as dangerous and desperately try to avoid feeling anxious.

Instead, these are effective techniques to help you feel calmer during the day (and who doesn't need that!), and also to take the edge off of the anxiety in difficult situations so that you can cope with them more effectively.

3. Changing Behaviours

This is a major part of addressing anxiety and it deserves a separate chapter. Please read on to learn about The Discovery of Oz the Terrible in Part 5.

If you enjoyed this article, follow me on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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This is Part 5 of our series of articles on anxiety.

Remember the book The Wonderful Wizard of Oz by Frank Baum?

If you do, you must recall how everybody was scared of the Wizard of Oz. The whole country lived in fear. But the powerful, never-seen wizard turned out to be a humbug -- an impostor. To reveal that truth, though, he had to be seen for who he was - not for who he was pretending to be.

In a similar way, anxiety (and its close relative Obsessive-Compulsive Disorder (OCD) tricks us into seeing danger in neutral, non-dangerous situations. To cite Oz, the Terrible, "...when you wear green spectacles, why of course everything you see looks green to you."

In the previous part of the article, we talked about how to deal with the first two components of anxiety --  Thoughts and Physical Reactions. Today, we will address the third and most important part -- the Behaviours.

Remember how Thoughts, Physical Sensations, and Behaviours affect each other? Sometimes, addressing behaviour is the most effective strategy for coping with anxiety.

But first,

What are the behaviours that keep the anxiety going?

When faced with a potentially threatening situation, we instinctively resort to two main strategies:

1. Escaping / Avoiding (whenever possible)

2. Trying to keep safe

Ironically, those same strategies that temporarily make us feel better are the main factors that keep the anxiety going. While we use them, they maintain anxiety, and in many cases make it worse. Gradually reducing and ultimately dropping those behaviours is a huge step to successfully coping with anxiety.

But why? Isn't it good to be safe? And what are those avoidance and safety behaviours anyway?

Initially, avoidance feels very good.

Imagine being anxious in social situations. When you manage to avoid going to a party, speaking in front of a group, or interacting with unfamiliar people, you feel relieved. In the short term, it feels good. In the long-term, however, avoidance actually feeds the anxiety.

When you avoid a situation, you don't give yourself a chance to find out that the predicted catastrophe has not happened. You never discover that Oz the Terrible is just a charlatan.

In addition, the relief that you experience when you avoid anxiety-provoking situations reinforces your belief that the situation that you escaped was, in fact, dangerous. Thus, you will be even more likely to avoid it in the future.

Avoidance seems innocent enough at first glance, but this behaviour is truly insidious.

In some cases, avoidance may make your world increasingly smaller. Think about it: if you live in Toronto and are afraid of cows, avoiding cows may not really interfere with your life in any significant way.

But what if you live in Toronto and are afraid of traveling on the 401, the major highway? If you avoid it long enough, you gradually strengthen the belief about the dangerousness of highways and the importance of avoiding them. With time, you may start staying away from the 400-series highways, moving on to avoid the smaller highway 7, and later, possibly, even the major roads. We routinely see patients that only came to treatment when they realized that they can't drive anywhere except inside their neighborhood. 

 When it is impossible to avoid a situation, people often resort to safety behaviours. Those are little tricks that help them feel a little less anxious. The most common ones are:

• Sitting near the exit in a movie theater or a church so that it's easy to escape if anxiety strikes

• Over-preparing

• Carrying a bottle of water everywhere to better cope with physical symptoms of anxiety

• Always having somebody to accompany you

• Pretending to be preoccupied with the phone in social situations (busily scrolling through Instagram)

• Avoiding eye contact

• Self-monitoring for concerning physical symptoms

• Asking for reassurance

• Checking and rechecking

• Using alcohol, drugs, or food to feel less anxious

• Watching carefully the tone of your voice and the pace of your speech carefully

• Saying as little as possible

• Rehearsing what to say

• Monitoring body language and trying to look relaxed

Unfortunately, like avoidance, those behaviours increase anxiety in the long term. And, in some cases, in the short term as well.

For example, in social anxiety, monitoring body language, facial expressions, and speech often leads to a person feeling even more awkward. In addition, so many cognitive resources are directed to self-monitoring that not much is left to be able to engage in the interaction.

So how can you get rid of those safety and avoidance behaviours?  

As you have probably guessed by now, the only way to break this vicious cycle is to gradually drop the safety and avoidance behaviours.

The first step would be to make two lists - one for avoidance behaviours, and another for safety behaviours that you use. Take your time doing it, as sometimes we are unaware of those sneaky patterns and it takes time to catch them.

Some of the behaviours are very subtle and elusive, such as busying yourself with some task when you have to be a part of a group, wearing layers of clothes to hide perspiration or a turtleneck to hide blushing, eating only small meals, speaking quietly, etc.

The next step is to gradually drop avoidance and safety behaviours. There is no rule as to which list to address first. We often suggest we start working on the avoidance list first, while temporarily leaving the safety behaviours as crutches to be removed later. However, if you feel like simultaneously dropping the behaviours from both lists - go for it!

On the other hand, some things on your list may need to be broken into smaller steps.

There are some very courageous people who after learning about how anxiety operates, choose to drop numerous safety and avoidance behaviours cold-turkey instead of addressing them gradually. This is very difficult, but if you feel you are fed up with your world being so small and that you are up to the challenge - definitely try.

So your new mottoes are:

• Face Fears

• Avoid Avoidance

• Screw Safety (behaviours)

And, just another bonus alliteration for you:

• Cultivate Curiosity

This is how you expand your world and it is a perfect antidote to being held hostage by anxiety and fear.

By now, you have learned about anxiety and why it is necessary for our survival. You have also learned about its potential causes, its components, when it becomes a problem, and how to deal with it. And we (hopefully) dethroned the deceitful Wizard.

There is one more thing left. In Part 6 we will talk about something that underlies most of the anxiety disorders: Intolerance of Uncertainty.

If you enjoyed this article, follow us on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

Related Posts

This is Part 6 of our series of articles on anxiety.

Well, maybe not really the best friend. But, definitely, something that we better learn to at least tolerate or, preferably, embrace.

In our sessions, we often ask patients to name things that they are totally certain of (other than the fact that we will all die one day). We have yet to hear of another absolutely certain thing. If you are the first one to come up with an idea, please email us, and I will add it to this article.

In spite of everything being uncertain, people with anxiety have a pretty low tolerance of uncertainty. In fact, Intolerance of Uncertainty is the common denominator of most anxiety disorders.

Thus, anxious people spend their life in an exhausting and never-ending pursuit of reducing uncertainty.

This is especially characteristic of people with Generalized Anxiety Disorder (GAD), but people with other anxiety disorders also experience it.

Unfortunately, in their futile attempts to reduce uncertainty, anxious people become preoccupied with analyzing all possible outcomes of a situation. In essence, it is this excessive worrying that leads to anxiety.

Ironically, people often mistakenly perceive this worry as useful, hoping that it will help them be better prepared for potentially threatening situations in the future.

Or, they feel as if worry gives them control over the situation.

Others believe that worry motivates them to do better.

It's as if some people worry to prevent worrying in the future.

Interestingly, people with high intolerance of uncertainty are anxious even when everything goes well, as they worry that things may change for the worse.

Oftentimes, people are not really aware to which extent the urge to reduce uncertainty affects their life. They engage in excessive research before making any decision, seek reassurance, or, alternatively, avoid making a decision altogether.

So, what is the effective way to reduce the uncertainty?

Unfortunately, there is not much that can be done to reduce ambiguity in our lives beyond basic common-sense stuff.

Uncertainty is unavoidable. Therefore, rather than fruitlessly attempting to increase certainty, the way to go about it is to concentrate your efforts on Increasing Your Tolerance of Uncertainty.

To do that, you have to be willing to experience the discomfort needed to let things unfold.

You can start small:

• Go to a restaurant without reading reviews and checking the menu.

• Limit the time researching the product you want to buy.

• Review your email only once before sending it.

• Start a conversation with a person at your yoga class.

Similar to facing other fears, when facing uncertainty and learning to tolerate it, you will learn two important things:

1. Most of your worries will not come true.

2. When things don't go as you wanted them to, you have better coping abilities than you had given yourself credit for.

It's true that initially, you will feel more anxious if you stop fighting uncertainty. But, on the other hand, if you learn to tolerate uncertainty better, a whole new world will open up in front of you. Not to mention, lots of free time (that you used to waste worrying).

Well, we are almost done. In the next section of the article, Part 7, I will list some additional helpful strategies to deal with anxiety.

If you enjoyed this article, follow us on Facebook for more great tips and resources!

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

Related Posts

This is Part 7 of our series of articles on anxiety.

1. Contain your worry

Schedule a "worry time" once a day for up to 15 minutes and limit your worrying to that time.

This worry time should be scheduled to take place in a specific location (say, a quiet room in your house). Set a timer for the end of the worry time.

If, during the day, you feel an irresistible urge to worry, promise yourself that you will devote your attention to this worry at the scheduled time.

After you decided to postpone the worry to the scheduled time, redirect your attention to something productive. An example would be making a shopping list, singing a song, cleaning a desk drawer, or just refocus on what you had been doing before you had the urge to worry.

But, watch out so that those distractions do not turn into avoidance behaviors. Remember: anxiety is not dangerous and shouldn't be avoided. You are just getting used to redirecting your attention and postponing your worry to a later time.

2. Create an algorithm for dealing with worry

Ask yourself, Is there anything specific I can immediately do to resolve the issue that I am worrying about?

If yes - do it, or at least write down a specific plan. If not — treat this worry as unproductive and postpone it.

A clue that your worry may be of an unproductive kind is if you keep asking yourself questions such as Why? or What if? Contain and postpone those! 

3. Create a Worry Box

Another way in which a strategy to contain your worry strategy may be helpful is if you worry about a situation that cannot be resolved.

Close your eyes and imagine a Worry Box (try to imagine it in detail). The box should have a lid. Visualize putting your worries in the box and putting the lid on. Then, put the box in an imaginary closet. You can always access the box and open it if you need. But the worry is safe there, there's no need to keep it in mind all the time.

4. Externalize your anxiety

When you feel anxious, remind yourself, "Oh, that's my anxiety. It's trying to keep me safe from danger."

5. Create and follow a routine

Often people that are predisposed to anxiety are especially sensitive to the lack of routine. This adds to unpredictability and stress which, in turn, increases anxiety.

6. Take risks!

When you are trying new things, you expand your world and learn to believe in yourself. This new courage will, in turn, make you more likely to further break free from your comfort zone and to tolerate uncertainty better.

7. Get active

As we discussed in Part 1 and Part 3 of this article, when we are anxious, physiological systems in our body get activated. To overcome that, we can use our bodies in three effective ways. We discussed the first two (breathing and progressive muscle tension and relaxation) in Part 4.

Another way is to exercise. If you ever tried it, you know that grounded feeling that you get after sweating at the gym and having a nice shower after.

Let's review the most important take-home messages from this seven-part series of articles:

Facts about Anxiety

• Anxiety is common.

• Anxiety is not dangerous.

• Anxiety keeps us safe.

• Anxiety itself is not the problem. It only becomes a problem when you see danger where there is no real danger.

• Anxiety-related perceptions and thoughts revolve around the themes of danger (physical, mental, or social), threat, or vulnerability.

• Our brain interprets those thoughts as a signal to prepare for danger.

• When faced with danger, our natural response is to escape.

• Our thoughts, physical reactions, and behaviors create a vicious cycle, with each element of it influencing the other two.

Strategies to Overcome Anxiety

• Try to separate the evidence and the reality from the way you feel.

• Practice progressive muscle tension and relaxation.

• Practice abdominal breathing.

• Face your fears.

• Screw safety (behaviors).

• Avoid avoidance.

• Cultivate curiosity.

• Learn to increase your tolerance of uncertainty.

• Start letting things unfold and observe them.

• Remind yourself that anxiety is uncomfortable, but not unbearable.

• Give additional strategies (above) a try.

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Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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