Lately, sex addiction has become a hot topic in the news.  Certainly, the biggest factor in this explosion of interest has been the revelation that Tiger Woods has had a seemingly infinite number of extra-marital affairs, and subsequent reports that he is undergoing treatment for sex addiction.

Is Sex Addiction OCD?

Every so often, the OCD Center of Los Angeles receives a call from a prospective client looking for treatment for sex addiction.  These individuals (or their spouses) call us because they believe, or more frequently, have been told by previous therapists, that their sexual behavior is evidence of Obsessive-Compulsive Disorder (OCD).  And invariably, they are surprised and confused when I inform them that sex addiction has absolutely nothing whatsoever to do with OCD.

In fact, the two conditions are radically different.  Yes, both conditions include obsessional thoughts and compulsive behaviors.  But people exhibit obsessive thoughts and compulsive behaviors in a whole host of conditions that are not OCD, including Anorexia Nervosa, Bulimia, Alcoholism, Drug Addiction, Pathological Gambling, Compulsive Shoplifting, Trichotillomania, and Body Dysmorphic Disorder.

So the question arises: what distinguishes sex addiction from OCD?  In a word…pleasure.

Very simply put, individuals who are addicted to sex get pleasure from their behavior.  Conversely, those with OCD get not a scintilla of pleasure from doing their compulsions.  In fact, in fifteen years of treating clients with OCD, I have never once had a client report getting anything resembling pleasure in the course of doing a compulsion.

To better understand how OCD operates, it is helpful to understand the concept of the Obsessive-Compulsive Cycle.  For the person with OCD, obsessions are specific, repetitive thoughts that are experienced as unwanted and extremely anxiety-provoking.  And like all humans, people with OCD don’t like the feeling of anxiety.  As such, those with OCD develop strategies do eliminate or reduce that anxiety.  The compulsive and avoidant behaviors seen in OCD are done with sole purpose of reducing or eliminating the immediate anxiety caused by these very specific thoughts.  And the compulsions are often done repeatedly and in a ritualized fashion, sometimes for hours, until the individual feels some relief from the anxiety caused by these specific thoughts.  This Obsessive-Compulsive Cycle is consistent and stable in all cases of OCD that I have ever seen.

Now let’s compare that to sex addiction.  Are the obsessive thoughts experienced by a sex addict prior to sexual activity unwanted and anxiety-provoking?  I would argue just the opposite.  It seems to me that the thoughts experienced by sex addicts are arousing and pleasurable.  Some might argue that sex addicts experience various conflicting emotions prior to acting compulsively, including anxiety.  But it seems self-evident that the primary feeling is one of sexual arousal.  The thoughts the sex addict experiences after the fact may be distressing, but prior to that sexual activity, the thought of having sex is primarily experienced as pleasurable and desirable.

Conversely, those with OCD never feel any pleasure related to an obsession.  Not for one second.  Their obsessions are experienced as the worst kind of mental torture.  In fact, on more than one occasion, I have had clients with OCD tell me that would gladly give up a limb if doing so would allow them to be free of their obsessions.

Likewise, the compulsive behavior done by a sex addict, whether it is sex with another person or masturbation, undeniably provides the individual with pleasure.  The individual with OCD gets no pleasure whatsoever from doing compulsions.  The person with OCD gets only a temporary reduction in anxiety related to the very specific fear about which they were obsessing.

Treatment for OCD vs. Treatment for Sex Addiction

Finally, it is also worth noting that if sex addiction is OCD, then by extension, it should respond to the same treatment as OCD.  Multiple controlled research studies have consistently found that the most effective treatment for OCD is a very specific type of Cognitive Behavioral Therapy (CBT) called Exposure and Response Prevention (ERP).  This therapy requires that the client purposely expose themselves to the very object or situation that generates their anxiety.  For example, if one obsesses about contamination, this might mean purposely having repeated contact with specific items that one perceives as “contaminated”.

Applying this principle to sex addiction would suggest that the best treatment would be for the sex addict to purposely and repeatedly watch porn, spend private, non-sexual time with prostitutes, etc.  This is not just unlikely to be a successful intervention – it is very likely to have the exact opposite of the intended effect.  Simply put, asking a sex addict to purposely be around sexual triggers is like asking a heroin addict to purposely be around heroin.

So, if sex addiction is experientially different than all other types of OCD, and it doesn’t respond to the same treatment that is known to consistently be the most effective treatment for OCD, it stands to reason that it isn’t OCD.

Next week, we will continue our discussion by answering the question: “If sex addiction isn’t OCD, then what is it.”

•Tom Corboy, MFT, is the director of the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions. He can be contacted director@ocdla.com.

Is this a good thing?  One of the most common issues we see in our clients with Body Dysmorphic Disorder (BDD) is excessive focus on the appearance of their eyes, including their eyelashes.  Latisse plays right into this common BDD concern.

Body Image Issues and Body Dysmorphic Disorder (BDD)

A recent British study found that the average woman has negative thoughts about her body 36 times a day.  While many might reasonably assume that other body parts (breast, lips, skin) are generally the focus of these thoughts, negative thinking about eyelashes is a fairly common body image issue for many women.  The huge market for eyeliners, mascara and other eye makeup products confirms how much attention many women already pay to their eye appearance. Marketing a drug that promotes eyelash growth reinforces the idea that women’s natural eyelashes are not good enough, and has the potential to lead to even more body image and BDD issues related to the appearance of the eyes.

Risks of Latisse

While discussing Latisse, it is important that we not overlook that this is a serious drug with potentially serious side-effects.  Among the reported side effects are:

• Redness and irritation of the eyes
• Eye pain and itchiness
• Bacterial infections
• Unwanted hair growth near the application area
• Darkening of the eyelid skin around the application area
• Change in eye color, especially in those with brown eyes

In fact, on September 10, 2009, the FDA reprimanded the drug’s manufacturer, Allergan Inc. of Irvine, California, noting that the firm’s advertising failed to appropriately note the side effects noted above.

Are longer, fuller eyelashes worth these risks? Apparently many women think so.  Latisse generated approximately $60 million in sales in 2009, and Allergan’s CEO reportedly expects the company to sell over $500 million of the drug in the next few years.  While there have been no studies investigating possible long-term consequences of using Latisse, that’s not stopping women from spending $120 a month to use it.

Treatment for BDD and Body Image Concerns Related to Eyes

While Latisse may provide a short-term benefit of enhanced lashes, the long-term outcome is a continuation of the belief that one’s natural lashes are not acceptable.  With each application of Latisse, a woman reinforces her belief that her lashes are not good enough…that she is not good enough.

A more effective solution to these types of body image and BDD issues would be for people to become more accepting of themselves, and to reject potentially dangerous drugs that chemically alter their bodies.  Four recent research studies have found that Cognitive Behavioral Therapy (CBT) is an effective means of addressing these types of body image and BDD concerns.  The cognitive component of CBT helps people learn to challenge the negative thoughts they have about themselves, while the behavioral component helps people change behaviors that reinforce that negative thinking.

While I may sound like a bit of a zealot on this issue, my main concern is that Latisse exploits the negative self image and BDD issues experienced by so many women.  Of course, Latisse is hardly the only product on the market that feeds into women’s body image issues.  But don’t we all deserve to go through life with a feeling of self-worth?  While Latisse and other products may provide hope of a quick fix for the negative thoughts people have about their bodies, it is only through acceptance of our bodies that we can truly feel good about ourselves in the long term.

•Tom Corboy, MFT, is the director of the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions. He can be contacted director@ocdla.com.

After ten years of ongoing debate, the numerous APA work groups investigating potential revisions to various diagnoses and categories to be included in a planned fifth edition have presented their suggestions to the APA.  Some of these changes are likely to be as controversial as current classifications in the DSM-IV, while others will pass barely noticed into the new DSM-5 (for example, the switch away from Roman numerals in the title).  A number of these proposed changes directly impact conditions treated here at the OCD Center of Los Angeles.  To wit:

OCD and Anxiety Disorders

The APA is considering changing the name of this category to Anxiety and Obsessive-Compulsive Spectrum Disorders.  This seems completely unnecessary, but harmless.  For years there have been reports that Obsessive-Compulsive Disorder was going to be removed from the Anxiety Disorders category, and reclassified in its own category.  The rationale for this idea was that OCD had been found to have a neurological basis.  That would have been spectacularly ridiculous.  It seems likely that, in time, researchers will discover that many, if not virtually all of the conditions in the DSM have some neurological basis.  The DSM-IV made quite clear that its focus was not on the cause of the disorders it classified, nor on the treatment of those conditions, but rather on the presenting symptoms that define the conditions.  Certainly, one of the primary defining characteristics of OCD is anxiety.  We have treated hundreds of individuals with OCD over the years, and I can comfortably say that the one thing that absolutely unites every single one of them is this – they are highly anxious about their obsessive and compulsive symptoms.

Panic Disorder

Currently, the DSM-IV lists two options for those with Panic Disorder

• Panic Disorder with Agoraphobia
• Panic Disorder without Agoraphobia

The DSM-IV also lists Agoraphobia Without History of Panic Disorder as a separate condition.  The APA is wisely considering condensing the two separate diagnoses of Panic Disorder into one, classified simply as Panic Disorder.  However, they are also planning to maintain Agoraphobia as a separate condition, but minus the “…Without  History of Panic Disorder” appendage.  This is utter nonsense.  In years of treating people with anxiety, I have never once seen a client who experienced Agoraphobia without having panic attacks.  While the theoretical possibility exists of someone having Agoraphobia without having panic attacks, the role of Agoraphobia in that person’s life would be to avoid experiencing a panic attacks.  Even in their new description of Agoraphobia, the APA refers to the fear of “panic-like symptoms” and “anxiety about having a panic attack, panic-like or other symptoms”.  The continuing inclusion of Agoraphobia as a separate condition is pointless and will unnecessarily complicate the diagnostic process.

Body Dysmorphic Disorder (BDD)

Body Dysmorphic Disorder is currently classified as a Somatoform Disorder, along with Hypochondriasis, Somatization Disorder, Undifferentiated Somatoform Disorder, Pain Disorder, and Conversion Disorder.  The APA is recommending two noteworthy changes for the classification of BDD.  First, it is suggesting that BDD be moved from its current category of Somatoform Disorders into the new category of Anxiety and Obsessive-Compulsive Spectrum Disorders.  I couldn’t agree more.  BDD has much in common with OCD and, very little in common with most Somatoform Disorders.

The second proposed change is to add a specifier for Muscle Dysmorphia, in which an individual’s obsession is that his or her body is too small or is insufficiently muscular.  The rationale provided by the APA is that Muscle Dysmorphia has differences from other forms of BDD, specifically higher rates of suicidality and substance abuse, and that the specifier will thus have clinical utility.

Hypochondriasis

The new DSM-5 is proposing to dramatically alter its conception of Hypochondriasis, which, as noted above, is currently classified as a Somatoform Disorder.  The plan is to combine four of the Somatoform Disorders – Hypochondriasis, Somatization Disorder, Undifferentiated Somatoform Disorder, and Pain Disorder –into a new condition called Complex Somatic Symptom Disorder (CSSD).  Conversion Disorder would remain a separate Somatoform Disorder, and BDD, as noted above, would be moved to the new Anxiety and Obsessive-Compulsive Spectrum Disorders category.

I would argue that Hypochondriasis is phenomenologically distinct from Somatization Disorder, Undifferentiated Somatoform Disorder, and Pain Disorder, and that combining it with these conditions ignores that reality.  Simply put, Hypochondriasis is not about the vague physical complaints, pain, or pseudoneurological symptoms seen in these other conditions.  Hypochondriasis is about the abject terror that one has a disease, illness or medical condition that will either result in death, or at the very least a miserable, pain-filled life.  In other words…Hypochondriasis is an anxiety disorder. In fact, the APA is suggests in this revision of the DSM that the fears experienced by those with what has heretofore been called Hypochondriasis now be called “health anxiety”.  As such, it would more appropriately be classified in the new Anxiety and Obsessive-Compulsive Spectrum Disorders category.

Apparently, the framers of the new DSM-5 agree that this is at least a possibility, as they note in their description of CSSD that “if patients present solely with health-related anxiety in the absence of somatic symptoms, they may be more appropriately diagnosed as having an anxiety disorder”.  Agreed.

Trichotillomania

The APA is considering two changes for Trichotillomania.  First, renaming the condition simply as Hair Pulling Disorder.  The Trichotillomania Learning Center (TLC), the largest advocacy and education organization in the world for this condition, has long proposed a name change along these lines.  The primary goals of the name change would be two-fold.  First to reduce confusion about the nature of the condition – let’s face it, as a name, Hair Pulling Disorder is a lot more to the point.  And second, to remove the stigma associated with the condition by virtue of the “-mania” part of its current name.  Hair pulling has nothing to due with “mania” or Bipolar Disorder, so this name change intuitively seems like a good idea.

The other change that the APA is recommending for Trichotillomania is to reclassify the condition in its planned new category of Anxiety and Obsessive-Compulsive Spectrum Disorders.  If this new category indeed gets formed, then this would be a far more appropriate place for Trichotillomania than its current home in Impulse Control Disorders, where it resides with Pathological Gambling, Pyromania, and Intermittent Explosive Disorder, none of which have any relationship whatsoever to Trichotillomania.

Skin Picking Disorder

Finally, the APA is beginning to pay attention to this condition, which the proposed DSM-5 succinctly (if incompletely) describes as “recurrent skin picking resulting in skin lesions”.  Currently, there is absolutely no mention of skin picking as a condition in the DSM-IV. It is as if it doesn’t exist, which would be news to the hundreds of people who have sought treatment at our center for this condition.  Many people believe their skin picking is a symptom of Obsessive-Compulsive Disorder (OCD), primarily because that is what they have previously been told by well-meaning, but misinformed therapists.  While skin picking has certain obsessive and compulsive features, and qualifies as an Obsessive Compulsive Spectrum Disorder,  it is quite different from OCD.  In fact, the condition with which Skin Picking Disorder has the most in common is Trichotillomania.

As a result of its non-existence in the DSM-IV, treatment centers that specialize in treating this heretofore unnamed, but fairly common condition, utilize various different names for it, including:

• Compulsive Skin Picking
• Chronic Skin Picking
• Neurotic Excoriation
• Dermatillomania
  
• Pathogenic Excoriation

Psychologist James Claiborn wrote a great article about this condition a few years back aptly titled Skin Picking: A Disorder in Search of a Name.  Hopefully, the APA will soon rectify this problem.  My only complaint is that rather than classifying Skin Picking Disorder in the DSM-5 as a codable disorder (and thus covered by insurance), the current proposal is to list it in the Appendix for Further Research.   While this condition certainly merits further research, it is hardly an unknown entity.  If the APA, as planned, creates a new category called Anxiety and Obsessive-Compulsive Spectrum Disorders, then this is where it belongs, right along side Trichotillomania.

Olfactory Reference Syndrome (ORS)

Like Skin Picking Disorder, the APA has long ignored Olfactory Reference Syndrome, which the proposed new DSM-5 perfectly describes as “preoccupation with the belief that one emits a foul or offensive body odor, which is not perceived by others.”  And like Skin Picking Disorder, the main problem is that the APA is planning to list ORS in the Appendix for Further Research.  We have treated many people with this condition over the years, and it is clearly an Obsessive Compulsive Spectrum Disorder with a strong anxiety component.  As such, it belongs in the new Anxiety and Obsessive-Compulsive Spectrum Disorders category.

The above are just a few of the many changes proposed by the APA for the upcoming revision to the DSM.  There are many other changes related to conditions that are not directly associated with OCD or other anxiety-based conditions.  The APA is accepting comments on the revisions until April 20, 2010.

•Tom Corboy, MFT, is the director of the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions. He can be contacted director@ocdla.com.

When the part of the brain responsible for making humans feel “sure enough” fails to kick into gear on its own, those with OCD and related anxiety-based conditions often use compulsive strategies to artificially create this sense of certainty. While this temporarily provides some assurance, the joy is short-lived, replaced by an overwhelming and seemingly unfair demand for re-assurance. As a strategy for suppressing the occurrence and effects of an obsession, reassurance seeking is a compulsion commonly employed by virtually all OCD sufferers, as well as those with related OC Spectrum Disorders such as Body Dysmorphic Disorder (BDD), Social Anxiety (Social Phobia), and Hypochondria (Health Anxiety).

The Problem with Reassurance

So why is reassurance such a big deal? To put it in clinical terms, when an individual seeks reassurance, they reinforce that they are unable to tolerate the discomfort of the uncertainty they are experiencing. At the same time, they reinforce that the best way to alleviate the discomfort of that uncertainty is to compulsively seek reassurance.

Concurrently, reassurance as a behavior sends the message to the brain that whatever unwanted thought set these events into motion must be terribly significant.  “If he goes through all of this just to know for sure, then this thought must be really important!”

Finally, reassurance is addictive. If reassurance were a substance, it would be considered right up there with crack cocaine. One is never enough, a few makes you want more, tolerance is constantly on the rise, and withdrawal hurts. In other words, people with OCD and related conditions who compulsively seek reassurance get a quick fix, but actually worsen their discomfort in the long term.

Three Types of Reassurance

For those with OCD and related conditions such as Body Dysmorphic Disorder,  Social Anxiety, and Hypochondria, reassurance seeking comes in three forms:

• Self reassurance. For individuals with OCD, the most obvious form of self reassurance is an overt checking compulsion, such as checking a door to ensure that it is locked.  Other less noticeable forms of self reassurance might include mentally reviewing an event or doing “mental compulsions”, such as such as repeating a “good” thought to ensure that a “bad” thought won’t come true. For someone with Social Anxiety, self reassurance might involve repeatedly doing a “mental review” of their performance at a party. For the person with BDD, a common type of self reassurance is body checking, wherein they compulsively look at themselves in the mirror in an attempt to get reassurance that they look OK.

• Reassurance seeking from others. Those with OCD and related conditions often ask others if things are OK, or manipulate others into telling them that things are OK. For example, a person with OCD may compulsively ask friends and family if they have washed their hands enough, or if they have run someone over with the car. Likewise, someone with Body Dysmorphic Disorder (BDD) may repeatedly ask others about their appearance, while someone with Hypochondria may compulsively ask family members about symptoms of certain medical conditions.

• Research reassurance. Individuals with OCD and related conditions frequently look for evidence online or elsewhere in an effort to prove to themselves that things are OK. One common example of this is what is colloquially known as Cyberchondria, wherein those with Hypochondria compulsively search the internet in an attempt to get reassurance they do not have a specific disease.

Managing the Urge to Seek Reassurance

Self-reassurance is the hardest of these to contend with because, like so many symptoms found in OCD and related conditions, these compulsions often go un-noticed until after they’ve been committed. Behaviorally, your best bet is to acknowledge the reassurance as soon as you notice it, and to stop it as soon as you can. Also, using Cognitive Behavioral Therapy techniques such as mindfulness and acceptance (the healthy practice of acknowledging and accepting thoughts and feelings without evaluating them or acting on them), one can learn to have an uncomfortable thought or feeling without over-valuing it or over-responding to it.

Resisting reassurance seeking from others often involves psycho-education of those who are most often on the giving end. Like the enabler to the alcoholic or drug addict, your loved ones might have a low tolerance for seeing you in pain, so they give you what you demand of them – even if it may actually hurt you in the long run. Consider your intent when asking for reassurance. Is your goal to remind yourself of what you already know? Is your goal to reduce your anxiety about something? If the answer to either of these questions is “yes”, then it’s best to resist asking for reassurance and to instead practice tolerating the discomfort.

Furthermore, be on the lookout for your own crafty manipulations. The word “manipulation” has a sinister connotation, but all it really means is the influencing of your environment to provide desired results. For example, merely mentioning the issue of toaster oven safety may be a not-so-subtle attempt to get reassurance, serving the same function as overtly asking if you really did turn the oven off.

One thing that seems to be very helpful with family members and partners is the formation of a reassurance contract. Simply put, the person with OCD or a related anxiety-based condition gives permission for their loved one to refuse reassurance or to reduce it to a bare minimum. When the individual asks for reassurance, the family member participating in the contract can say something like, “Remember you asked me to help you, and that means I can’t answer this question. Now let’s go do something else…”

Finally, when it comes to resisting the wealth of information (and misinformation) available from the web and other sources, it’s best to turn the computer off altogether when you find yourself just wanting to know something “for sure.” In fact, there’s no time like the present…so let’s see if you can move on from this blog without knowing for sure if you fully understood it.

•Jon Hershfield, MA, is a psychotherapist at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions.  He can be contacted jon@ocdla.com.

Phobia Treatment in Non-Traditional Venues

For those with ophidiophobia (fear of snakes) or arachnophobia (fear of spiders) there is now a novel place to get help. The Bristol Zoo in England is offering two seminars specifically for those who have a fear of snakes and spiders. The classes will be led by zoo staff and include a counselor who specializes in phobias. These programs allow those with ophidiophobia and arachnophobia the opportunity to face their fears head-on. The zoo also offers a follow-up course for those who have already attended prior spider phobia courses and want a refresher.

On a similar front, the Royal School for Veterinary Studies at the University of Edinburgh in Scotland has recently begun to offer specialized training specifically for veterinary students who have phobias of exotic animals. Recent years have seen a dramatic increase in the number of people having exotic animals such as snakes and rats as pets. As a result, there is a rising demand for veterinarians who can provide health care for these animals. However, enough veterinary students have fears of these types of animals that the Royal School now offers this specialized approach to help student vets conquer their phobias.

It is unfortunate that more schools, organizations, and businesses don’t offer programs that address the phobias of their consumer base. For example, a number of airlines used to offer programs to help customers move beyond their aerophobia (fear of flying). American, Delta, and Northwest airlines all had programs for aerophobia, and all were based on the principles of Cognitive-Behavioral Therapy (CBT). One can guess that the financial woes currently being experienced by most airline companies may have played a role in the demise of these offerings.

Cognitive Behavioral Therapy for the Treatment of Phobias

All of the above examples point to how phobias impact peoples’ lives, and how non-traditional treatment venues could utilize Cognitive Behavioral Therapy principles to help address the phobias of their constituents. The OCD Center of Los Angeles has treated a number of clients over the years with similar phobias who unfortunately did not have such options available to them.

In one case, our client was a medical student with severe emetophobia (the fear of vomit and/or vomiting). Cognitive Behavioral Therapy (CBT) quickly helped him move beyond this fear and get on with his education and career. Likewise, we treated a student getting a degree in biology who was terrified of rats. The first year of his coursework required close contact with lab rats. Even though the rats were dead, our client was still terrified of them. A short course of CBT quickly led to a significant reduction in the phobia. And we have successfully treated numerous clients with a fear of flying who had previously been unable to travel for years.

One of the unfortunate realities of phobias is that many people go years suffering with a condition that is treatable. Cognitive Behavioral Therapy is relatively quick, and has been repeatedly found by researchers to be the most effective treatment of phobias and other anxiety disorders. If you are experiencing a phobia, you owe it to yourself to find a Cognitive Behavioral therapist who specializes in the treatment of phobias.

•Tom Corboy, MFT, is the director of the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions. He can be contacted director@ocdla.com.

BDD and Changing Cultural Views of Cosmetic Surgery

While dissatisfaction with one’s body is fairly common (and probably has been throughout history), one significant cultural shift that has occurred in recent years is that many are now willing, and financially able, to have surgeries and other procedures that were very rare just a generation ago. A mere 30 years ago, cosmetic procedures were uncommon – both the cost of the procedures and the cultural attitudes of the day were strong disincentives against having one’s appearance altered. Now, parents give their teenaged daughters nose jobs for birthday presents, and housewives have botox parties. And while cosmetic procedures used to be an almost exclusively female phenomenon, more and more men are now having work done as well.

Exploitation of Patients with BDD

While the easiest culprit to blame for this cultural shift is “the media” (surgically enhanced celebrities, airbrushed models, etc.) there is also a significant financial aspect to this issue. Not only are these procedures now less expensive, they are also being heavily marketed by big pharma. And many cosmetic surgeons are not above providing – and sometimes pushing – procedures that their patients simply do not need. We treated one man with Body Dysmorphic Disorder whose obsessions were with the appearance of his teeth and gums. He had a dentist who performed multiple, very expensive, totally unnecessary, procedures on our client’s perfectly nice looking mouth. I ultimately had to call his dentist and forcefully tell him he was harming our client and that he had to stop performing these unnecessary procedures. We also treated a client with BDD who was scheduled to have one minor cosmetic procedure for a legitimate skin problem. But on the morning of her surgery, as she lay on the gurney being prepped, her cosmetic surgeon talked her onto adding two additional (very expensive, totally unnecessary) procedures.

Finally, here is a personal story. In 1990 I had to have a nose job. Not a cosmetic nose job, but a long-delayed functional fixing of my nose which had been broken since high school. The doctor with whom I initially consulted kept telling me that he could do a (very expensive, totally unnecessary) cosmetic nose job at the same time. I repeatedly told him I had no interest in changing my appearance, but he kept revisiting the topic. The message was very clear – my nose, which I had heretofore considered aesthetically just fine, was unacceptable and worthy of a (very expensive, totally unnecessary) surgery. I ultimately dropped him and elected to have my nose fixed by an MD who willing to do the required surgery without trying to increase his revenue at my expense.

BDD and the Ethics of Cosmetic Surgery

One of guiding principles of medical ethics is “first, do no harm”. But, as we discussed in an earlier posting, two studies have found that cosmetic surgery in patients with Body Dysmorphic Disorder frequently results in increased BDD symptoms. Studies have also found that these surgeries are less effective than Cognitive-Behavioral Therapy in reducing the distress experienced by those with BDD.

Despite these findings, there is no shortage of unethical cosmetic surgeons, dentists, and other medical professionals quite willing to financially exploit the insecurities of people with Body Dysmorphic Disorder. Perhaps the most egregious example of this is the case of the late Michael Jackson, who by all accounts appeared to have BDD. Unfortunately, he was in the position of being able to afford numerous (very expensive, totally unnecessary) cosmetic procedures designed to alleviate his insecurities about his appearance. The result was a face that, in the end, scarcely looked human.

It is time the issue of unethical cosmetic surgeons came under scrutiny by state medical boards and the media so that the public is protected from doctors willing to exploit those with BDD.

•Tom Corboy, MFT, is the director of the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions.  He can be contacted director@ocdla.com.

The Good

Research Findings

2009 brought us closer to understanding, and ultimately finding better treatments for, Social Anxiety, Trichotillomania, and OCD.  But perhaps the most noteworthy research story was the discovery that, using Cognitive Behavioral Therapy (CBT), traumatic memories can be “reconsolidated” in such a way as to reduce anxiety attached to these memories.  Many equated this research to the plotline of the 2004 film Eternal Sunshine of the Spotless Mind.  But this is actually better.  Unlike the movie, this research doesn’t reveal ways to erase memories.  Rather, it suggests a way to maintain memories, while reducing the excessive, maladaptive anxiety response to certain memories experienced by those with PTSD and phobias.  And this research ultimately holds great promise for treating not just these two conditions, but all anxiety disorders.

Zack Greinke

Certainly the feel-good story of the year was Kansas City Royals pitcher Zack Greinke. In 2006, Greinke was placed on the disabled list due to Social Anxiety and depression.  Greinke sought treatment, and three years later, he has a Cy Young Award on his mantel.

The Health Care Bill

Just last week, the U.S. Senate passed its version of the ever-controversial national health care bill.  Both the Senate version and that of the House of Representatives appear to go a long way in finally establishing parity for the treatment of psychiatric conditions.  But this item is listed here conditionally – the final bill has yet to go through conference, in which the Senate and House versions of the bill will be reconciled and presented to President Obama for signing.  So there is still plenty of time for the Democrats to display their customary incompetence, and for Republicans to exhibit their seemingly Pavlovian, knee-jerk obstructionism when it comes to anything even remotely humane.

Howie Mandel

The comedian / TV star / reality show host wrote the most talked about OCD book of the 2009, Here’s The Deal, Don’t Touch Me.  He is to be commended for his forthright description of his struggles with OCD and ADHD which have done a lot to confront what he rightly calls the “stigma attached to mental health”.

The Bad

Howie Mandel

No, that’s not a misprint.  While Mandel certainly deserves kudos for talking openly (and humorously) about his OCD, he has at the same time sent the message that there is little that can be done to effectively treat OCD.  He speaks openly of his ongoing compulsions and avoidance behaviors, and acknowledges years of therapy.  But it appears he has not seriously pursued Cognitive-Behavioral Therapy (CBT), which is the only treatment that has been repeatedly shown to manage OCD symptoms long-term without medication.  If Mandel wants to significantly reduce his many OCD symptoms, he needs to see a Cognitive Behavioral therapist specializing in OCD.

Swine Flu Paranoia

Did any other story inspire so much needless anxiety in 2009?  Despite numerous reports that Swine Flu was likely to be no more serious than standard seasonal flu, the country seemed gripped by the fear of getting sick and dying.  Sales of gloves, masks, and antibacterial cleaners skyrocketed, as the country seemed to develop a nationwide case of OCD.  Yet, the Swine Flu turned out to be fairly mild, and thus far, fewer people have died from it than from standard seasonal flu in past years.  That’s not meant to diminish the loss of those who have perished from this disease.  But the above point bears repeating – fewer people have died from H1N1 this year than from standard seasonal flu in past years.

Latisse

It’s no surprise that big pharma would figure out a way to make a silk hat from a sow’s ear.  In this case, Allergan decided to take the side effect of unwanted hair growth related to its glaucoma drug Lumigan and market it as Latisse, a drug to enhance eyelash growth.  This would not be too terrible by itself – after all there’s no denying that many women want thicker, fuller eyelashes.  But the OCD Center treats many women who have Body Dysmorphic Disorder (BDD) that is specifically focused on their eye appearance, including their eyelashes.  Latisse has never been tested for long-term consequences, and it has a whole host of unwanted side effects.  Are pretty eyelashes worth bacterial infections, eye pain, itching, discoloration of the skin around the eye, and changes in the pigmentation of your iris? Put another way, do we really need another product that tells women that their bodies aren’t good enough?

The Ugly

Eyelash transplants

While not-fully-tested drugs to increase eyelash length are bad, eyelash transplants for Trichotillomania are worse.  A lot of publicity was given this past year to a British report of a successful eyelash transplant surgery. News reports detailed the ₤3500 procedure (that’s $5,600 to you and me), which replaced the eyelashes that had been pulled out by a 19-year-old girl with Trichotillomania.  There is just one huge, glaring problem with this story – if the girl has Trichotillomania, she is likely to pull out the new lashes! In fact, Alan Bauman, M.D, a Florida doctor who specializes in hair restoration, says that those with Trichotillomania are not good candidates for this procedure for this very reason.  The $5,600 would have been better spent getting qualified Cognitive-Behavioral Therapy (CBT) for the girl’s Trichotillomania.

Anti-Science Psychotherapy

The journal Psychological Science in the Public Interest published an editorial that rightly condemned the anti-science bias of many psychotherapists.  As the report noted, many therapists choose their approach to treatment “like kids make choices in a candy store: they look around, maybe sample a bit, and choose what they like, whatever feels good to them”.  The editorial led to stories in Newsweek and other mainstream media outlets, and ultimately set off a firestorm of controversy.  Of course, those opposed to the editorial were, surprise, therapists who don’t use evidence-based treatments.  I have one simple question for these head-in-the-sand types: why are you opposed to using what has been shown to work, and how do you justify continuing to charge clients for treatments that have not been shown to work?

Penile Implants

This was a no-brainer for ugliest story of the year.  A Beverly Hills cosmetic surgeon has developed a process for “the subcutaneous implantation of a non-liquid, pliable, FDA approved and patented medical grade silicone prosthesis” in the penis.  Nothing particularly new here, right?  Penile implants in various forms have been around for years.  But what’s most disturbing in this case is that the doctor is marketing the process specifically as a treatment for Body Dysmorphic Disorder (BDD)! It’s bad enough that some men feel so badly about their penises that they are willing to have dangerous, invasive surgeries to “enhance” their size.  But when a cosmetic surgeon targets people with a psychiatric condition, especially BDD, he is actually at great risk of doing harm.  Numerous research studies have shown that individuals with BDD often have surgeries in an attempt to deal with their distorted views of their bodies, and that these surgeries are less effective than psychotherapy in reducing the distress these people experience.  In fact, two studies have found that cosmetic surgery in patients with BDD frequently results in increased BDD symptoms.  Ethical cosmetic surgeons view BDD as a contraindication for surgery, not as an untapped market.  While I imagine there are certain situations that warrant penile implants, having a psychiatric condition that results in insecurities about your penis is certainly not one of them.

And on that note…Happy New Year!

•Tom Corboy, MFT, is the director of the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions.  He can be contacted director@ocdla.com.

Do I Have OCD?

I’ve had intrusive thoughts, images, and impulses of being catapulted down a flight of stairs and stabbing myself in the eye when cutting up vegetables.  I’ve had disturbing thoughts about dropping my newborn niece in a big pot of boiling water and dropping babies to the ground as I held them.  When juicing fruit and vegetables, I had an image of my parakeet flying into the machine and coming out as juice.

Something else you should know is that I do not have OCD.  While these thoughts were out of the ordinary and unsolicited, they did not bother me.  While everybody has bizarre, unwanted thoughts, people with OCD attribute meaning to these thoughts and the anxiety related to them.  They frequently feel the need to investigate or make sense of these intrusive thoughts, and may desperately try to prove to themselves that these thoughts are not premonitions of events to come or of a subconscious desire.  People with OCD often need to know with 100% certainty that these events will not occur and that they are not a bad person for thinking them.

How to Respond to OCD Thoughts

If you have OCD, you too can take the meaning away from your bizarre, unwanted thoughts, the same way as people who do not have OCD.  Using simple Cognitive Behavioral Therapy (CBT) techniques, you can learn to respond differently to these unwanted thoughts.  Whenever you get an intrusive thought, even if it gives you anxiety, do not judge it or try to make sense of it.  Remind yourself that everybody gets bizarre thoughts, that they do not mean anything, and that they are an expected part of having OCD.  You are the one who decides if your thoughts are problematic.  Your reaction is the problem, not the thought itself.  After all, OCD thoughts can be viewed as funny, interesting, creative, and quirky.  Embrace and welcome your OCD thoughts and they will lose power over you.

•Stacey Kuhl-Wochner, LCSW, is a Licensed Clinical Social Worker at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions.  She can be contacted stacey@ocdla.com.

Most people who call us with emetophobia are initially quite surprised to learn that this problem has a name, and often equally surprised to learn that they are not the only person in the world to suffer with it. Often, they have secretly struggled with emetophobia for years.  Some have been misdiagnosed with anorexia or depression, and as a result, have wasted years being inappropriately treated for conditions they don’t have.

While the primary fear in emetophobia seems quite simple (the sufferer is terrified by the possibility of vomiting, and/or the possibility of seeing others vomit), the individual’s response to this fear can become quite complex.  Often the person with emetophobia spends hours every day focused on monitoring and controlling how their gastro-intestinal (GI) tract feels.  As a result, every meal becomes a battle to ensure that they never feel any GI discomfort such as gas, cramps, fullness, nausea, etc.  In practical terms, this often means having very restricted diets because the client is afraid of any food that they believe may possibly lead to any GI distress.  This also often means that restaurants, parties, and family gatherings are simply off limits, as the client may fear eating even “safe” foods any place but home.

In many cases, the client has adopted numerous non-food based avoidant strategies in an effort to ensure they never experience any GI distress.  This can include avoidance of television programs or movies with images they fear will cause GI distress, not driving or flying, and avoidance of socializing with friends whom they associate with the possibility of GI distress.

Unfortunately, family and friends of people with emetophobia are often dismissive of the suffering experienced by the individual with this sometimes crippling problem.  Equally problematic are family members who enable and accommodate the problem, which usually results in a worsening of symptoms.

Fortunately, emetophobia responds extremely well to Cognitive-Behavioral Therapy (CBT).  While this treatment requires a strong commitment on the part of the client, the results can be life changing.  If one is willing to challenge their fears, they can, over a relatively short period of time, regain normal eating habits, and put an end to the avoidant strategies so commonly seen in emetophobia.

•Tom Corboy, MFT, is the director of the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions.  He can be contacted director@ocdla.com.

Perhaps it takes a few moments, or maybe it takes no time at all for the OCD search engine to drum up some piece of the broken puzzle.  But inevitably, you find what you are looking for.  The obsession is still there, still unresolved, still malicious and unfair.  The lump in your throat swells and the other physical symptoms of anxiety begin to surface.  Something is wrong and the day has only just begun.

Immediately, your OCD brain begins to engage in a series of mental exercises pitting the unwanted thought against reality, trying to force them to match up or reveal themselves as permanently incongruent.  Someway, somehow, you have to get that sense of closure to indicate that “it” is not you.  Otherwise, you may never get out of bed.

This is “mental checking”, and it is a common feature of Pure Obsessional OCD.  The scan feels like an automatic part of life, no different than the first yawn or stretch.  It happens throughout the day, often without you really being conscious that you are doing it.  When it is not automatic, it presents itself as necessary, like the annoying reminder message for your computer’s antivirus software.  It is important to realize that mental checking is a compulsion.  And despite its automatic presentation, it is subject to the same treatment mechanisms employed when challenging other OCD compulsions with Cognitive Behavioral Therapy (CBT).

In short, mental checking is a behavior.  It is the act of looking for your OCD obsession with the presupposition that you will in some way be able to squash it and get relief.  Furthermore, since we always find what we are looking for when what we are looking for is evidence to justify action, we feel we need to do something about the obsession.  This follow-up compulsion is a form of mental ritual aimed at neutralizing the OCD thought.  It may be playing an event over in your head to make sure it was handled appropriately (also known as retracing), or it may be repeating a series of “good” thoughts to outweigh the so-called “bad” ones.  But the initial behavioral compulsion that puts this OCD cycle into motion is the mental checking, and it is among the more challenging behavioral compulsions to resist because it often appears to precede the unwanted thought.

For people with Pure Obsessional OCD, there are three opportunities to challenge mental checking, listed here in decreasing order of difficulty:

• preemptive resistance
• concurrent resistance
• retrospective resistance

Preemptive resistance may appear impossible until you are well into a course of Cognitive Behavioral Therapy (CBT).  Preemptive resistance requires that you have an awareness of your OCD tendency to check.  If you have developed this awareness, you are more able to see opportunities for mental checking before they happen, and to see them as opportunities to resist checking.  If you have OCD, you may feel an urge to check when you become aware of the absence of your obsession.  Use this urge as evidence that you should re-direct your focus, rather than seeking certainty that the obsession has been dealt with.  In other words, the urge is your clue – it is your signal to resist doing the compulsion.

Somewhat more tangible an objective is concurrent resistance.  If you have already begun mental checking, you are already down the path to digging up an otherwise dormant, unwanted thought.  This is where you can jump in and say, “Wait!  This is mental checking!  This is OCD, and I don’t need to do this!”  At that moment, the challenge you face is to pull yourself back to the present.  What matters now is not whether your obsession has been dealt with.  What matters now is interrupting and stopping the pointless mental compulsion.

Finally, retrospective resistance may at times be the only tool left in your OCD toolbox.  You have already searched for and found the obsession.  You have already tried some compulsive mental exercises in an effort to make the obsession go back to where it came from.  But all is not lost.  You can still use the power of mindfulness and clinical self-observation to fully acknowledge that this was mental checking.  Take this opportunity to remember what it felt like to look for the obsession.  Identify that urge, and acknowledge that it sent you down the path of grappling with the same old OCD junk.  You might be surprised how effective this post-compulsion labeling is in helping you better develop the skills of concurrent and preemptive resistance.

We often find ourselves sending the wrong message to the OCD brain when we engage in compulsions.  We feel fear and engage in a mental (or physical) behavior to flee from that fear.  The brain remembers this as evidence that the behavior saved us from the fear.  But a more effective message to send to our brains is that the behavior is pointless and so is the fear. (For more information on this process, see our previous post on Exposure Therapy for OCD and Anxiety.) So even if OCD may have won a skirmish on the mental field by pushing you into a bout of mental checking, you can still win the battle by reminding yourself that what happened was nothing more than a compulsion.  Next time it won’t be so easy to fool you.

Now get out of bed.

•Jon Hershfield, MA, is a psychotherapist at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions.  He can be contacted jon@ocdla.com.