Jon Hershfield, MFT, of the OCD Center of Los Angeles discusses treatment of Harm OCD using Mindfulness Based Cognitive Behavioral Therapy.   Part two of an ongoing series.

Mindfulness Based CBT is a key component of successful treatment for Harm OCD

In our previous installment of this series, I defined the symptoms of a sub-type of Obsessive Compulsive Disorder (OCD) known as Harm OCD. The defining characteristics of Harm OCD are intrusive thoughts of a harming/violent nature (obsessions), and the behavioral response of engaging in physical and mental strategies (compulsions) in an effort to relieve the inherent discomfort one experiences when having these thoughts. In upcoming articles in this series, we will discuss each of the main elements of Cognitive Behavioral Therapy (CBT) used to treat this form of OCD.

Psychoeducation and the Treatment of Harm OCD

The first step in treating Harm OCD is psychoeducation. Unfortunately, sufferers who are not already well-versed in OCD are likely to approach treatment with extreme apprehension and doubt. This is because the pain of being burdened with unwanted thoughts of causing harm has worn them down to a point that they may genuinely believe it’s possible that a therapist will take one look at them, smile, and call the men in white coats. So before any discussion of treatment can begin, a Harm OCD sufferer has to have a better understanding of the nature of the condition, and why some people are hyper-aware of these types of thoughts, while others appear not to be.

To know that something is dark, I must have in my mind some concept of what it means to be bright. To understand peace, I must also have thoughts that are defined by their violent content. Otherwise there would be no frame of reference for understanding its opposite. For most, a thought of happiness is unencumbered by thoughts of sadness. But in OCD, the sufferer’s awareness of this “un-thought” is greater. This awareness is then responded to with fear and disgust, thus making it much more powerful and significant than it need be. This process is described well in Lee Baer’s excellent book on Pure Obsessional OCD, Imp of the Mind.

Violence exists. Therefore having violent thoughts is a normal and essential part of being conscious. For those suffering with Harm OCD, what makes this condition so challenging is the presentation of these normal thoughts at such an intense and intrusive level. If these intrusive, unwanted harm thoughts were simply passing by, we could overlook them. But these violent thoughts often hit hard and stick. For those with Harm OCD, it is not easy to acknowledge and accept the presence of these thoughts as being merely some sort of magnification of a “normal” thought process. For this, we must turn to treatment.

Treatment for Harm OCD

The only form of treatment worth taking seriously for Harm OCD (or any type of OCD) is Cognitive Behavioral Therapy (CBT). This approach to therapy for OCD has been repeatedly researched, and has consistently been found to be the most effective treatment for all forms of the condition, including Harm OCD. Within the overall framework of CBT, one will gain the most benefit from three specific CBT techniques: Mindfulness-Based CBT, Cognitive Restructuring, and a specific behavioral therapy technique known as Exposure with Response Prevention (ERP).

Mindfulness Based CBT For the Treatment of Harm OCD

If you look at the brain as a thought-generator, then you can define the mind as that which receives and processes these thoughts. Few thoughts make it from the brain to the processing center. Most thoughts are out of sight, out of mind. They barely register as blips on the radar screen and no matter how peculiar they may be, they are given little to no attention. When they do make it to the processing center, (i.e., to our full awareness), these thoughts are assumed to be relevant to our experience.

If I have a thought about the sky being blue, that will most likely not be placed front and center for further analysis. It doesn’t matter much what I do with that innocuous bit of information. But if I have a thought about something itching, then that thought will jump to the front of the line so I can assess what behavior it should be met with. Scratching seems appropriate, unless I’m posing for a picture or have peanut butter on my fingers. Then maybe I’ll just acknowledge the itch, but not respond to it.

The problem with OCD is that thoughts sometimes skip to the front of the line as part of a glitch in the system. They slip through a crack in the dam and show up uninvited. So the same part of me asking what I should do about my itch is suddenly appearing to ask what I should do about murdering my family.

You Are Not Crazy and These Are Normal Thoughts

I’ll have to sit with the uncertainty over how many readers have stopped at this point. After all, how can a thought about hurting a loved one or killing myself be called normal? To understand this, one must take a moment to consider what a thought really is. A thought is a mental event. It is a word we use to describe a link between a chemical reaction in the brain and our awareness of it. A chemical event occurs, something happens, and then we become aware of that thing and call it a thought. The judgment of “normal” vs. “abnormal” is used only to describe how we interpret that thought and what behaviors we choose to apply it to. The thought itself is nothing more than ones and zeroes, so how can it be anything but normal?

As I write this and I consider the kinds of thoughts that Harm OCD sufferers find themselves stuck on, the following thought pops into my head: “I will go home and murder my family when this article is finished”. Now, I can try to justify my awareness of this thought by attending to the context of what I was writing previously – that I was considering examples of typical Harm OCD thoughts. But I can’t know for sure if that’s the truth. Perhaps that thought actually represents a genuine, hidden desire to kill my family. How can I know for sure? Well, I can’t know and I don’t particularly care. After work, I will probably go home and have dinner. We’ll have to see what happens after that. In any case, the harm thought itself is not problematic. Its content may disturb you, but its existence is unimpressive at every level. It is, after all, just a thought.

As discussed above, harm thoughts, ugly as their content may appear, are normal, uninteresting events that occur in the brain. The problem is that individuals with Harm OCD judge these thoughts, over-process them, and distort them into threats. But thoughts are just thoughts, not threats. If a harm thought occurs, but there is no awareness of it, it either exists or does not, but in any case it is not a threat. If a harm thought occurs and we are aware of it, the tendency is to go straight into judgment and analysis. This immediately takes the concept of “thought” and changes it to an object of fear.

Treatment with Mindfulness-based CBT focuses on training yourself to maintain an observational, rather than judgmental, stance towards your thoughts, feelings, urges, and physical sensations. It means letting go of the need to be the actor/director and taking the opportunity to simply be the camera instead.

For mindfulness to be effective at all, one must start from the perspective of accepting the presence of their unwanted harm thoughts. Note that accepting that a harm thought exists is not the same thing as accepting what the harm thought implies after you judge it. The goal of Mindfulness Based CBT is disarmingly simple – to accept the reality of the existence of our intrusive, unwanted thoughts, without attributing any special meaning, value, or judgment to them. For those with Harm OCD, this means accepting that harm thoughts exist, without assuming that they must have some inherently profound meaning about our character and/or intent.

Because many Harm OCD sufferers fear that their thoughts represent a real and  imminent danger that must be immediately addressed, the very practice of mindfulness itself often becomes a challenging form of behavioral therapy known as Exposure with Response Prevention (ERP).  Future installments in this series will focus on ERP, as well as on a technique known as “Cognitive Restructuring”, and how modifying the way you think about the content of your thoughts can help you choose less compulsive behavioral responses to the unwanted thoughts of Harm OCD.

To read part one in our series of articles on Harm OCD, click here.

•Jon Hershfield, MFT, is a psychotherapist at 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.  Jon can be contacted at jon@ocdla.com.

Cognitive Behavioral Therapy (CBT) is the most effective treatment for Dermatillomania (compulsive skin picking)

In my previous article on Dermatillomania (also known as Compulsive Skin Picking, or CSP), I wrote about a classification system for skin picking. Let’s review “The ABC’s of Skin Picking”:

An “A” is something that almost anyone would pick. This could be a piece of dry skin hanging off your arm, a pus-filled whitehead on your chin that pops at your mere touch, or a scab that’s barely hanging on which you can easily detach.

A “B” is a “bump”, pimple, scab, etc. that only a skin picker would pick, frequently causing it to bleed, ooze, scab, and possibly become infected. This in turn will cause two additional problems – it will cause the picker significant distress, and it will give him or her something new to pick at later. In my experience, clients with Compulsive Skin Picking classify at least 50% of their picking as “B’s”.

“C” stands for “Create”, meaning the individual with CSP is not picking at anything objectively “real”, but in the process of picking at her skin, she “creates” something such as a blemish, scratch or scab. A “C” is something that only someone with Dermatillomania would pick. There is often nothing apparent on the skin, but the picker starts picking or scratching, and in the process creates a wound.

Treatment for Dermatillomania / CSP

Unfortunately, there are very few psychotherapists who understand Compulsive Skin Picking, and even fewer who know how to treat it appropriately. The sad truth is that most therapists have never even heard the term “Dermatillomania”, and their initial response to an individual presenting with the symptoms of this condition is either to suggest SSRI anti-depressants, or to simply say “stop doing that”. Of course, if it were that simple, nobody would suffer with with this often misdiagnosed condition.

As with most Obsessive Compulsive Spectrum Disorders, the most effective treatment for Dermatillomania is Cognitive Behavioral Therapy (CBT).  When treating Dermatillomania with CBT, the two most useful techniques are Habit-Reversal Training (HRT) and Mindfulness Based CBT.  Increasing awareness of one’s picking patterns is central to the process of Habit Reversal Training, and is generally done by keeping skin picking logs. These logs help the individual to identify picking patterns that they previously may not have realized or understood.  For many with Dermatillomania, Habit Reversal Training may also be made easier if they use “habit-blockers” such as gloves, which help to provide a barrier to unconscious picking.

Mindfulness Based CBT for Compulsive Skin Picking

The central thesis of Mindfulness Based CBT is that much of our emotional distress is a function of over-reacting to unpleasant, unwanted feeling states that are a normal part of the human experience. The goal of Mindfulness Based CBT is to learn to accept and tolerate these normal feeling states, despite the fact that they are unpleasant.

The first of two important factors to address in reducing the picking of “B’s” is to gradually learn to tolerate the urge to pick. If a “B” is left alone, it will either go away or become an “A,” sometimes overnight. So, start small and build on your successes. When you see or feel a “B,” acknowledge it and tell yourself you will wait at least 24 hours to look at it or touch it again. In 24 hours, if the bump or blemish is still there, you can then decide whether to pick it or not.

What? I’m giving you permission to pick? Yes, if you have waited at least 24 hours. By waiting, you teach yourself that you are able to resist the urge to pick immediately – that you can wait it out and see what happens. The more you practice doing this, the better you will become over time at resisting the urge to pick. Remember, picking is a choice – you don’t have to pick something just because you see it or touch it, or just because you have an urge to do so. This is what you teach yourself by mindfully acknowledging and accepting the urge to pick without automatically giving into that urge.

As you build up your tolerance for delaying the urge to pick, you will find that you can add on to your 24-hour wait time. Next, you might go for 36 hours, then 48, and so on. Over time, this practice will ensure that you are only picking “A’s,” the kinds of things almost anyone would pick.

For most individuals with Dermatillomania, skin picking is a self-soothing technique that helps them to better modulate their feelings. The second factor to work with in reducing the urges to pick (and you can do this concurrently with having a “wait time” to pick) is to identify the feelings you have been “getting out” through skin picking. What is the metaphor for your skin picking? What are you trying to get out? Are you sad, bored, angry, lonely, or anxious? Do you constantly “pick on yourself” internally with a critical inner voice telling you all the ways that you aren’t perfect?

I’ve found that a very effective way to express these feelings is to write them out. You can journal and say anything you want. You can shred what you’ve written afterwards to protect your privacy and confidentiality. Once you get the feelings you’ve been suppressing out in this healthy way, you are likely to experience diminished urges to “get things out” by picking your skin. In other words, by allowing yourself to experience, acknowledge, and tolerate your uncomfortable feelings, you are less likely to need skin picking as a self-soothing technique.

When you teach yourself these two new techniques, the likelihood of getting to a place where you are relatively pick-free is significantly improved. Remember, turn off the perfectionist voice that tells you that you “must” change overnight. Success is a series of steps in the right direction, and building the practices of tolerating the urge and expressing your feelings in a constructive way can lead to success with conquering Dermatillomania.

To read part one in our series of articles on Dermatillomania / Compulsive Skin Picking (CSP), click here.

•Karen Pickett, MFT 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, including Dermatillomania.  Karen can be contacted at karen@ocdla.com.

"Harm OCD" is a common variant of OCD, and is very treatable with Cognitive Behavioral Therapy (CBT)

Harm OCD is a manifestation of Obsessive Compulsive Disorder (OCD) in which an individual experiences intrusive, unwanted, distressing thoughts of causing harm. These thoughts are perceived as being ego-dystonic, which simply means that the thoughts are inconsistent with the individual’s values, beliefs and sense of self. Harming obsessions typically center around the belief that one must be absolutely certain that they are in control at all times in order to ensure that they are not responsible for a violent or otherwise fatal act.

It is not fair to say that one form of OCD causes more pain than another. In my experience of treating individuals with OCD, those with compulsive hand washing appear to be in no less pain than those who live in fear of being sexual deviants or psychopaths. What sets Harm OCD apart is the way in which it attacks the things we love the most, and does so with such brutality and lack of mercy as to astound even the most creative minds. The moments that we most want to be highlighted by memories of peace and contentment suddenly become contaminated by mental imagery of horrific violence and feelings of relentless guilt.

Common Obsessions in Harm OCD

The mind is a landscape. Being conscious means wandering (mostly aimlessly) around this landscape and encountering the wonderful, the terrible, and the mostly irrelevant. As owners of the mind, we are entitled to go anywhere we wish. In the case of Harm OCD, we find ourselves visiting places in the mind that we would rather do without. However, like any landscape, places we avoid become overrun with weeds, their growth intruding into the well-groomed, peaceful areas of the mental garden, and becoming a relentless burden.

In Harm OCD, as in all forms of OCD, individuals experience obsessions, and in response, perform various compulsive behaviors designed to relieve the discomfort associated with those obsessions. Here is a list of common intrusive thoughts associated with Harm OCD:

• I will suddenly snap and violently attack:
  • My significant other or ex
  • My child (especially common in Perinatal and Postpartum OCD)
  • My parent or other family member
  • My nephew/niece/godchild
  • A disabled or ill person
  • A baby
  • A friend
  • A stranger
• I will fail to respond to disgusting violent or sexual thoughts appropriately and will reveal myself to be a monster.
• I will suddenly have an uncontrollable urge to push someone into traffic, jump out a window, or experience some other impulse that will result in me being responsible for my death or someone else’s death.
• I will be overwhelmed by harming obsessions and have to act on them to relieve the pressure.
• I will lose consciousness somehow and commit violent acts that I do not remember.
• I will fail to wash or turn off something appropriately and I will be responsible for someone being horrible hurt or killed.
• I will accidentally poison someone.
• I will hit someone with my car and not know it until the police track me down.
• I will lose my sanity and commit suicide.

Common Compulsions in Harm OCD

Because the compulsions in Harm OCD often go unnoticed by others, it is generally considered to be a type of what is colloquially referred to as “Pure Obsessional OCD”, or “Pure O”.   But individuals with Harm OCD almost always exhibit various compulsions that fall into four categories – checking, avoidance, reassurance seeking, and mental rituals.  Here are some common compulsions typically seen in Harm OCD:

Checking

• Excessively looking in the rear-view mirror to make sure you did not strike someone with your car.
• Looking back at people you walk past or examining them for signs that they have may have been harmed by you.
• Checking your body for signs of a struggle or any indication that you have harmed yourself or someone else.
• Checking to make certain that no items which could be used for harm are visible. For example, locking up tools or placing knives out of reach.

Avoidance

• Avoidance of people that trigger the unwanted thoughts. For example, avoiding being left alone with your young relative for fear that you will hurt them, or avoiding taking a hike alone with your girlfriend.
• Avoidance of places that trigger the unwanted thoughts. For example, avoiding crowded bus stops where you fear you might push someone into traffic.
• Avoidance of items that trigger the unwanted thoughts. For example, staying away from sharp objects such as knives for fear that you might use them to harm someone.
• Avoidance of information that triggers unwanted thoughts. For example, avoiding watching or reading the news where you think you might possibly hear about murder, or avoiding movies or TV programs that you believe might have violent scenes in them.

Reassurance Seeking

• Asking others to confirm to you that they believe you would not do a horrible thing.
• Asking others to confirm that you did not hurt someone and somehow fail to remember it.
• Confessing unwanted thoughts in the hopes that their response will indicate they do not believe you are a dangerous or bad person.
• Repeatedly researching the difference between OCD and sociopathy.

Mental Rituals

• Mental review/mental checking. This is a form of self-reassurance seeking that involves reviewing thoughts and memories of events in an attempt to gain certainty that you have not harmed anyone. This also involves mentally reviewing various reasons why you would or would not commit a violent act.
• Compulsive flooding – Trying to force yourself to imagine violent acts in an attempt to prove that you are disgusted by them and would not do them.
• Thought neutralization – Purposefully forcing yourself to think a positive or otherwise contradictory thought in response to a harm thought.
• Compulsive prayer/magical rituals – Repeating prayers or mantras by rote in response to unwanted thoughts.
• Repeating behaviors – A combination of physical and mental compulsivity, this would typically involve repeatedly starting tasks over or extending them in an attempt to complete the task without having an unwanted “bad” thought.

Harm OCD might be experienced as an extension of a lifelong battle with the disorder, or it may develop spontaneously later in life. It is not uncommon for children with OCD to struggle with intrusive thoughts of causing harm to their parents, siblings, or peers, either through thoughts of literally attacking them or through the distorted belief that “bad” thoughts may cause bad health or bad luck to someone they care about.

Late onset Harm OCD can be particularly unsettling because without the context of understanding OCD and the various ways it can interfere in one’s life, it may appear that you have simply gone insane. It is not uncommon for someone who previously displayed little or no signs of OCD to suddenly become aware of a harm thought in the middle of some stressful experience, and to then find themselves engaging in compulsions all day trying to suppress thoughts of hurting someone they would never dream of hurting.

OCD sufferers may also discover violent obsessions appearing only after extended battles with other forms of OCD have run their course. Untreated, OCD naturally gravitates toward whatever is most likely to produce compulsive behavior. So when one obsession stops producing, another one often takes its place until treated. In fact, it is the intensity with which we experience love for our children, partners, relatives, etc. that makes them targets for OCD – they are the most likely to stir in us the greatest motivation to protect.

Self-Harm in OCD

Some individuals may also experience intrusive thoughts of self-harm, often brought about by imagining ways to escape anxiety, and then being terrified of what their brain came up with. It is important to note that fear of self-harm is an entirely different phenomenon from actual self-harm behaviors such as cutting. Similarly, the fear of committing suicide is a different issue than genuine suicidal ideation. Some with Harm OCD experience an obsessive fear of self-harm, often related to unwanted intrusive thoughts of losing control, while actual suicidal thinking has to do with the fantasy of ending one’s life. It is important to note that individuals with Harm OCD are at no higher risk of acting violently than the general population, and that having Harm OCD does not indicate that one is a danger to themselves or others.  That said, treatment providers should discuss these types of thoughts with their clients to clarify and determine issues of intent.

Treatment of Harm OCD

As with other forms of OCD, it is important that the sufferer seek treatment with a psychotherapist who specializes in Cognitive Behavioral Therapy (CBT) specifically for the treatment of OCD. The primary CBT technique used in treating Harm OCD is the same as that used in treating other types of OCD, and is called Exposure and Response Prevention (ERP). Unfortunately, many individuals with harming obsessions seek out traditional talk therapy or psychodynamic therapy, both of which can swiftly worsen a Harm OCD sufferer’s condition by encouraging them to further examine these meaningless thoughts, which only serves to unnecessarily inflate their importance.

In the next installment of this series, we will discuss in-depth the treatment of Harm OCD using Cognitive Behavioral Therapy. For now, if you are experiencing Harm OCD, remember that you are not alone, that your condition is very treatable, and above all, that you are not crazy.

To read part two in our series of articles on Harm OCD, click here.

•Jon Hershfield, MFT, 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.  Jon can be contacted at jon@ocdla.com.

Effective Strategies and Predictable Complications in the Treatment of Orthorexia

In our previous article about Orthorexia, we described this relatively unknown and misunderstood condition.  In this, the second and final installment in this series, we discuss strategies and pitfalls in the treatment of Orthorexia.

Orthorexia can be effectively treated with Cognitive Behavioral Therapy (CBT) and Mindfulness

Orthorexia, being a somewhat new conceptualization of a psychological disorder, is under-researched and often misunderstood within the mental health and medical communities.  Many mental health professionals have found success treating individuals with Orthorexia using evidence-based treatment methods that are used to treat other Eating Disorders, OCD, and related OC Spectrum Disorders.

Cognitive-Behavioral Therapy (CBT) and Mindfulness are two highly effective treatment methods used to treat Orthorexia.  Using CBT, individuals with Orthorexia learn to challenge and change their distorted thoughts (cognitions) related to their body and the foods they eat.  Education about nutrition and what is considered “healthy” should also be integrated into CBT when treating Orthorexia, using logical, evidence-based strategies.

Using mindfulness-based cognitive behavioral therapies such as Acceptance and Commitment Therapy (ACT), clinicians can help those who suffer with Orthorexia to gain greater awareness and acceptance of uncomfortable thoughts, feelings, sensations and urges related to food and their body.  This approach also helps clients to become more aware of and conscious of their food consumption.  The goal is for clients to become more comfortable with their bodies and their actual health (as opposed to their feared bad health).  Using these techniques, sufferers can change their relationship with a variety of foods and with their food-related anxiety.

The primary behavioral component of treatment for Orthorexia is Exposure and Response Prevention (ERP).  Some common ERP assignments might include the following:

• Gradually introducing a broader variety of foods into the client’s diet, including healthy foods that the client has previously decided were unacceptable;
• Restricting, and ultimately eliminating time spent researching food;
• Restricting, and ultimately eliminating time spent discussing the health values of food;
• Returning to normal social interactions, including meals with others.

It is important to note here that clients are encouraged to eat a healthful diet.  Some mistakenly believe that giving up their Orthorexia eating style will be the same as eating a bad diet.  Nothing could be further from the truth.  The goal is not to help the client learn that all food is healthy – after all, there are foods that are legitimately unhealthy, especially if eaten to excess.  Rather, the goal is to help the client learn to have a more balanced perspective towards food, and to eat in a manner that is both healthy and enjoyable.  In other words, the goal is not to teach the client to eat a diet of Big Macs and Slurpees, but rather to be able to eat based on choice, not fear.

Orthorexia In Perspective

Diagnosing and treating Orthorexia can be complicated by a number of factors:

First, the culture at large, and the news media in particular, reinforce on a daily basis that we should be hyper-conscious of health, weight, and nutrition, and that we should eat as purely as possible.

Second, people who experience Orthorexia often do not see that their obsessive thoughts and compulsive behaviors are problematic.  They see their diets as ideal and healthy, and see others’ diets as disgusting and unhealthy.  Great pleasure and satisfaction are gained from the belief that they have mastered and will continue to perfect their diet.  This may become an issue during treatment, as sufferers are likely to initially reject any suggestion that their diet is problematic, and equally likely to resist the idea that change would benefit them in a positive way.

Third, those with Orthorexia may initially feel significant discomfort during the exposure therapy that is so critical to treatment.  Exposures typically involve eating foods that individuals with Orthorexia deem “unhealthy” or “impure”.  They may at first have a strong visceral reaction when trying foods that they have long identified as disgusting and toxic.  The ultimate goal of exposure is for the client to learn that they need not fear less-than-perfect foods, that they may actually enjoy such foods in moderation, and that eating them does not result in a catastrophic outcome.

Fourth, those with Orthorexia are even more likely than the average client to reject the use of anti-depressants and other medications that may potentially help to reduce their anxiety and obsessionality.  Individuals with Orthorexia frequently view such medications as “poison”, and clinicians should be prepared for the possibility that the client will never be open to pharmacotherapy in any way.

Orthorexia is a significant and growing problem that requires serious consideration by the medical and psychological communities.  While Orthorexia is not yet recognized by the APA as a formal, free-standing diagnosis, failure to accurately identify and treat the condition will result in serious problems for many people who don’t necessarily meet the requirements for a formal eating disorder diagnosis.  Fortunately, Orthorexia responds well to treatment with Cognitive Behavioral Therapy (CBT) and Mindfulness Based CBT, especially if the clinician is able to first help the sufferer recognize the excessive and distorted nature of their thoughts and behaviors related to food purity.

To read part one of our series on Orthorexia, click here.

•Kimberley Quinlan, 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, including Orthorexia.  She can be contacted kimberley@ocdla.com.

The concept "reasonable doubt" may help some better understand OCD

When most people think of Obsessive Compulsive Disorder (OCD), they think of people excessively washing their hands or repeatedly checking their doors and windows to see if they are locked.   But there are many variations of OCD, including a subtype in which people have intrusive, unwanted thoughts about harming spouses, friends, co-workers, strangers, or even their own children. Sometimes called “Harm OCD”, this condition falls under the category of what is commonly called Pure Obsessional OCD, or “Pure O”, because both the obsessions and the compulsions are primarily mental.

People with Harm OCD often perform mental checking rituals just as others with OCD might physically check their stove over and over again in an effort to feel sure that they haven’t accidentally left a burner on.  They might repeatedly monitor and analyze their mental processes in an effort to convince themselves that they will not act on their unwanted thoughts, and that their intrinsic character or their love for the other person is strong enough to prevent them from doing some sort of harmful action.  They may also repeatedly seek to determine whether they are a bad person for even dreaming up such a thought.  And it is quite common for those with harming obsessions to repeatedly ask others for reassurance that they have not harmed someone or that they are not going to do so.  But as anyone with Harm OCD knows, these efforts to gain certainty almost never provide the desired reassurance for the OCD sufferer, and the unwanted thoughts almost always increase in frequency and intensity.

Through my years of working with those with OCD, I cannot tell you how many times I have heard the names Andrea Yates and Susan Smith brought up in therapy. Numerous times I have been asked by a client suffering with Harm OCD, “Is it possible that I will go crazy and kill my child like that woman in Texas”? Now, we can add one more name to the list of infamous women accused of killing their own children – Casey Anthony.

I was so shocked by the verdict this past summer in the Casey Anthony trial. Ms. Anthony was charged with murdering her two-year-old daughter Caylee, and from reading news reports, the evidence presented at trial seemed to support a conviction.  Yet in July, a jury of her peers found that there was “reasonable doubt” about Casey Anthony’s culpability in the death of her daughter. Now Ms. Anthony is a free woman, having been found not guilty of murder, despite the fact that: a) she did not report her child missing for 31 days; b) she was convicted on charges of lying to the police numerous times about her whereabouts around the time of her daughter’s disappearance; c) her child’s skeletal remains were found in a swampy area with three pieces of duct tape across her mouth; and d) court testimony revealed that around the time Caylee disappeared, Casey Anthony’s car reeked of human decomposition. And while her guilt seems obvious to me and many others, the jury members apparently had enough “reasonable doubt” that they acquitted her of murder.

Recently, I was thinking about what the jury was tasked with during their deliberations. They were given instructions to decide her guilt “beyond a reasonable doubt”. But how does one measure the reasonability of one’s doubt? How much doubt is not enough or too much? What quantity of doubt is just under the threshold of acceptability for which you would send a person to death row? It seems too subjective for such an important decision as convicting someone of murder with the possibility of a death sentence.  And this may have been why the jurors found it easier to err on the side of acquittal rather than conviction.  They may have felt that they needed a smoking gun – a higher level of certainty.

Likewise, the individual with harming obsessions must subjectively decide if his/her doubt is “reasonable” or not. Being a therapist who specializes in treating those with OCD, I can only imagine what an especially difficult task quantifying reasonable doubt would be for many of my clients. People with OCD and related OC Spectrum Disorders such as Body Dysmorphic Disorder (BDD), Hypochondria (Health Anxiety), and Social Anxiety are on a constant quest for answers to unanswerable questions. They seek to quantify that which cannot be quantified, to gain certainty when it is only possible to be “pretty sure.” These are questions that most people who do not have OCD can accept despite their inevitable doubts.  But for many people who experience OCD or a related spectrum condition, “reasonable” doubt often feels unbearable.

Doubt is such an intrinsic part of OCD that the condition has often been referred to as “the doubting disease. Some common doubts seen in OCD and related OC Spectrum Disorders include:

• Are my hands clean enough to ensure that I won’t accidentally make someone sick through casual contact?
• Am I straight enough to to be certain that I am not actually gay?
• How do I know if I really love my spouse?
• What level of pain is a enough that I should visit a doctor to see if I have a serious medical condition?
• What is the right amount of eye contact to avoid being seen as socially inappropriate?
• How do I know whether I am a good person or a bad person?
• If I become angry at my child, does this mean that I do not love them enough, and that I am close to mentally snapping and harming them?

The only realistic answer to these and similar questions is to accept that nobody has 100% certainty on these issues, and to stop the mental checking. The goal is to make decisions based on what is “most likely”, given all the evidence. For people with OCD, it may feel terrifying to make that leap and take that chance because their brain is telling them that absolute certainty is required.

But these questions can become less important if you stop responding to them. Using Cognitive Behavioral Therapy (CBT) and Mindfulness techniques, people with OCD and other anxiety conditions can learn that the best response is to tolerate uncertainty and to observe their thoughts (and the accompanying discomfort) as they rise and fall naturally. In most cases, their worst fears will be disconfirmed without any intervention. Conversely, continuing to respond and react to these distressing thoughts will only lead to an endless cycle of questions and more attempts to find answers. This cycle only serves to reinforce the OCD, and creates the exact opposite from the desired effect – more uncertainty.

•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.

Not all skin picking is the same.

Everybody picks their skin sometimes, right?  If you tell your friends or family that you pick your skin, many of them might say “Oh, I do that, too”.  So, how do you know if your skin picking is severe enough to warrant a diagnosis of Dermatillomania, also known as Compulsive Skin Picking or Chronic Skin Picking (CSP)?

There are a variety of ways in which assessment of skin picking occurs. Self-assessment might occur by the person doing the skin picking when an individual realizes that he or she is causing scabs, scars, and/or infections. A person with Dermatillomania may also be aware that he or she is avoiding social situations, including work, school, and/or social functions such as weddings and parties.  After all, those who have picked to the point of bleeding and scabbing may be too embarrassed to be seen by others who might judge them or ask questions about their skin.

An assessment of Dermatillomania might also come from a dermatologist, aesthetician or family member who sees the physical and emotional consequences of the person’s skin picking. This person may recommend that the skin picker seek professional assistance for the picking.

Generally, most people do pick their skin, pimples, nails, or cuticles at some point. So, what makes the difference between someone who has CSP and someone who does not?

I heard a great classification of skin picking in a workshop by Dr. Charles Mansueto at the Trichotillomania Learning Center’s (TLC) 2006 Conference. I was inspired to create my own version of his classification system. I use it with all of my skin picking clients, and I call it the ABC’s of Skin Picking.

An “A” is something that almost “anyone” would pick. This could be a piece of dry skin hanging off your arm, a pus-filled whitehead on your chin that pops at your mere touch, or a scab that’s barely hanging on which you easily detach.

A “B” is a “bump”, pimple, scab, etc. that only a skin picker would pick. This is something that would either become an “A” over time or go away on its own if left alone. But, a skin picker will frequently start picking at it and make it significantly worse. It may then bleed, ooze, scab, and possibly become infected.  This in turn will cause two additional problems – it will cause the picker significant distress, and it will give him or her something new to pick at later. In my experience, I have found that clients with CSP classify at least 50% of their picking as “B’s”.

“C” stands for “Create”, meaning the individual with CSP is not picking at anything objectively “real”, but in the process of picking at her skin, he or she “creates” something such as a blemish, scratch or scab.  A “C” is something that only someone with Dermatillomania would pick. There is often nothing apparent on the skin, but the picker starts picking or scratching, and in the process creates a wound.

Treatment for Dermatillomania / CSP

The recommended treatment for CSP is with a trained psychotherapist who specializes in treating this misunderstood and often misdiagnosed condition.  Effective treatment focuses on Cognitive-Behavioral Therapy (CBT), with an emphasis on Habit-Reversal Training (HRT) and Mindfulness Based CBT.

In Cognitive Behavioral Therapy for Dermatillomania, the first behavioral goal is to stop picking any “C’s” – in other words, to stop creating new skin problems where none previously existed. Usually, a skin picker can learn to do this relatively easily by becoming more aware of their picking patterns.  Building awareness is generally done by keeping a skin picking log, and with the assistance of a habit-blocker such as wearing gloves.

Gloves provide a barrier to unconscious picking, and help in two ways.  First, the skin picker cannot easily pick at existing scabs, blemishes, etc.  Second, the gloves prevent identification of new places to pick that would otherwise be felt by random, unconscious, mindless “investigation” (touching) of the skin. If you are a skin picker, the previous sentence may resonate with you, and you may say, “I do that!” That would make sense as the two main triggers for skin pickers are touching and looking at their skin.

Removing the opportunity to touch your skin by wearing gloves is a good first start to becoming more aware of your unconscious “scanning”, and reducing the impulse to pick. After you get used to using a “habit blocker” like gloves, the focus of treatment turns to reducing your picking of “B’s.” What are the two most important factors to address in successfully reducing picking of “B’s”? You can read about that in Part 2 of The ABC’s of Skin Picking, coming soon.

•Karen Pickett, MFT 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, including Dermatillomania.  Karen can be contacted at karen@ocdla.com.

Jon Hershfield, MA, of the OCD Center of Los Angeles discusses common challenges seen in the treatment of Sexual Orientation OCD, also known as HOCD or Gay OCD.  Part four of a four-part series.

Sexual Orientation OCD - also known as HOCD or Gay OCD - is best treated with Cognitive Behavioral Therapy

In my previous blog on Sexual Orientation OCD (aka HOCD), I looked at some of the potential sub-types that appear in this condition.  While they are all treated with various Cognitive Behavioral Therapy (CBT) strategies, crippling fear can lead people toward beliefs that impede therapy.  Here are some thoughts about treatment issues I commonly hear from HOCD clients.

My Big Gay Secret Self

Many HOCD sufferers, regardless of sub-type, become preoccupied with the idea that other people might think that they somehow “appear” gay.  As a result, some men with HOCD may over-attend to the way they dress, opting for baggy, neutral choices rather than fitting, stylish choices that they might associate with homosexuality.  They may pay special attention to the way they speak or even the way they hold a drink, trying to eradicate any possibility that a person may mistake them for being gay.  Women with HOCD may over-attend to the length of their hair, or whether their clothes are “feminine” enough.  Both men and women with HOCD are likely to obsess about their body type and whether there is something inherently “gay” about it.

Some of this distorted thinking comes from limited or erroneous information they have collected about homosexuals, which leads them to compulsively avoid stereotypes that really have little to do with homosexuality.  Still the HOCD persists with the notion that the sufferer has some clue of what gay “looks like” and then compels them to avoid that.  For most, this appears not to be a fear of negative evaluation, but more a fear that this imagined person who may somehow identify them as gay will actually be seeing into their soul – that if another person calls them gay, this person is seeing their “true self” and this will confirm their worst fear… gay denial!

There is no gay denial.

There is no latent homosexuality, there is no hidden self.  It’s something someone made up one day.  It does not exist.  There is no secret version of yourself waiting to be discovered (yes, I anticipate lots of angry emails from your psychoanalyst).  I think it is important to recognize that people often choose to modify their behaviors to fit with what they think society expects of them.  In some cases this results in people of one sexual preference choosing to live the lifestyle of another sexual preference as a way of avoiding what they see as the negative consequences of accepting themselves as they are.  This could be done in order to avoid professional, cultural, religious, or other consequences.  Of course, there may be a small percentage of the population that somehow is not conscious of what their preferences are, and appear surprised when they “come out” as gay.  I am assuming these people exist because I have seen them on television, but then I see a lot of rare and bizarre things on television.

In all seriousness, there are people who claim not to have known their sexual preference until they met the right person.  This concept is very disturbing to an HOCD sufferer.  Yet it cannot be referred to as “coming out” since it is really more like “waking up.”  And this real “coming out” doesn’t begin with fear, but with yearning

Get Out of the Way

The most effective treatment for all forms of OCD is a type of Cognitive Behavioral Therapy (CBT) called “Exposure with Response Prevention” (ERP).  The most common impediment to ERP treatment for HOCD is the continued practice of compulsive behavior throughout the exposure itself.  Usually this comes in the form of self-reassurance.  For example, many HOCD sufferers may attempt to overcome their fears by exposing to gay pornography, gay neighborhoods, or other things that are likely to trigger their discomfort.  Among the most common self-ERP attempts I hear involves reading online “coming out” stories.  All of these may be good ideas for ERP work, but they can easily backfire for the following reason: trying to prove you don’t like the porn, or that you don’t belong in the gay neighborhood, or that the person in the coming out story is nothing like you will never work.

ERP only works if the person resists doing this mental ritual, and instead accepts whatever thoughts and feelings the OCD may throw at them without protest.  In more intensive ERP, you are not only accepting the thoughts, but actively agreeing with them, diving head first into the fear instead of tip-toeing around it.  Any effort to analyze the exposure for evidence of your sexual orientation results in the brain confirming once again that your sexuality is up for debate.  If instead, your behavior indicates to the brain that the presence of triggering material does not result in mental rituals, then your brain will begin to recalculate its position on the importance of knowing the certainty of your sexual orientation.  In other words, if you stop doing mental compulsions aimed at finding certainty about your sexual orientation, your brain will learn that it is not necessary to have that certainty.

A common fear related to ERP treatment is the distorted idea that accepting the presence of gay thoughts in your mind somehow leads to a likelihood of acting out gay behaviors.  This OCD logic has the sufferer in a double bind in which doing compulsions feels like a way to protect oneself from becoming gay, but at the same time actually fuels the obsession about one’s sexual orientation.  When someone with HOCD stops doing the compulsions, they often see this as dangerously opening the door to unwanted gayness.  This is not unique to sexual orientation OCD, as it is an identical frame for the harm OCD sufferer who worries that accepting harm thoughts will lead to violence, or the contamination OCD sufferer who worries that not washing will lead to contracting a terrible disease.  It is important to remember, then, that ERP for OCD always feels like you are doing something wrong.  This is because what you thought was right (compulsive behavior) is actually the source of the problem.

Feeling Gay

As the ERP work intensifies, the OCD fights for its own survival by leading the sufferer to fear that they are “feeling” gay.  Feeling gay is an interesting phenomenon because it is oxymoronic.  A truly gay person does not over-attend to gay feelings, but sees them as a normal part of their existence.  It’s no more conscious than the feeling of me having brown hair.  A gay person doesn’t sit around “feeling gay” any more than a straight person sits around feeling straight.  It’s the OCD that makes someone over-attend to their feelings, and it’s that same over-attending that distorts these feelings into something to obsess about.  An HOCD sufferer is likely to report feeling gay when they do exposure work and being terrified by this.  But the fact that they report “feeling” gay actually means they don’t have any idea what it is like to actually be gay!

An additional challenge to ERP treatment often presents itself when a person starts to initially see the benefits of the treatment.  At that point, the person habituates to things that would previously have triggered a significant spike in their anxiety.  As this habituation takes place, the person’s thoughts and feelings become more congruent with those of non-HOCD sufferers.  In other words, the individual becomes less upset by the presence of the unwanted thoughts and feelings they experience related to the issue of sexual orientation.  At this juncture, some with HOCD then begin to obsess that they are not “bothered enough” by the trigger, and then use this as evidence of their homosexuality.  This is sometimes referred to as (awkwardly enough) a “backdoor spike” because the OCD goes from identifying the fear as evidence of being gay, to now identifying the lack of fear as evidence of being gay.

What often goes unnoticed in HOCD and similar obsessions is that demonstrations of disgust and terror can also be compulsions, which are essentially behavioral strategies for avoiding or reducing discomfort.  This does not mean they always feel good to do (often they do not).  By actively causing oneself to be repulsed by gay thoughts, a sufferer can then avoid the discomfort that comes from thinking that the gay thoughts are acceptable and then inferring that this makes them gay.  It’s enough to make anyone dizzy.

Whether the OCD is using fear or ambivalence as its threat, the goal of treatment needs to remain firmly focused on accepting whatever is going on inside as simply going on.  Thoughts happen, feelings happen, sensations happen, and nowhere in this does anyone have certainty as to what it means.  We guess and we tolerate whatever discomfort we imagine could come from being wrong.  Life without OCD is lived in the present, making choices based on current preferences, not predictions, and choosing labels based on patterns in those preferences.

The Fear of Not Having HOCD

One of OCD’s more sinister sneak attacks is the threat that having HOCD is just a cover for not accepting that you’re gay.  Of course, sufferers of all types of OCD obsess about not having OCD.  The “scrupulosity” OCD sufferer may see OCD as a way of denying they are sinners, while a “contamination” OCD sufferer may debate whether they are just inherently lazy about cleanliness, while someone who obsesses that they might be a pedophile or a murderer will worry that identifying their problem as being OCD is just a way to avoid accusations of being a monster.

All of these people miss the larger point, which is that non-OCD sufferers do not obsess about having OCD.  To be clear, virtually everyone has some obsessions and compulsions, but roughly 2-3% of the population has them to such an extent that it impairs functioning and is diagnosable as a disorder.  So a non-OCD sufferer may be disturbed by an intrusive thought or may engage in a pointless ritual, but they do not get so completely trapped by this cycle that their quality of life is affected, and they are unlikely to be concerned with whether or not they have OCD.

HOCD sufferers often seek reassurance from their treatment providers that they do indeed have OCD.  This is really the same reassurance-seeking compulsion that they engage in elsewhere when trying to gain certainty that they are not gay.  Just as the HOCD sufferer must learn to tolerate uncertainty related to their orientation, they must also learn to tolerate uncertainty related to their diagnosis.  If somehow they managed to be in such denial that they convinced an OCD specialist to diagnose them with a disorder they didn’t have, then they must have been obsessing over that denial to such an extent that they compulsively sought reassurance from a treatment provider who would tell them they weren’t gay.  That sounds like OCD to me.

Gay Fantasy and OCD

Some people have gay sexual fantasies.  Some people have OCD.  Some people have both and none of this has to do with one’s sexual orientation.

Sexual fantasy in itself is a healthy thing.  While there are ways in which it can be used compulsively or destructively, for the most part mindfully observing arousal thoughts is an activity we should all be able to enjoy as one of the perks of having a brain.  Most, if not all, sexual fantasy involves taboo.  It is this state of actually allowing ourselves to entertain and fully embrace and accept “wrong” thoughts that is so stimulating and freeing.  It is good because it is oh so bad.  For example, a heterosexual man may conjure up in his mind the fantasy of cheating on his wife.  This man is not necessarily interested in cheating on his wife and in all likelihood he would run awkwardly away from an opportunity to actually do so.  If he walked into a room and a beautiful stranger were laying there saying “take me,” he would probably not be comfortable.  “This is a real person,” he thinks, “someone’s sister or daughter!  Plus, are they disease free?  When was the last time they showered?  What will they think of me afterwards?  What will I think of myself?  Will my wife find out?  Would this hurt my wife?  Will I be able to live with the guilt?”  He can accept the fantasy, but not the reality, because the fantasy appears wrong and the reality to him actually is wrong.  The appearance is exciting, the reality is distressing.

For many heterosexuals, gay fantasies are not technically unwanted thoughts themselves.  They are taboo, and while the reality might be unpleasant, the fantasy is undoubtedly stimulating.  But a gay fantasy should not to be confused with an HOCD obsession, which is an intrusive, unwanted thought about the fear of being gay.  For people with actual gay fantasies who also have HOCD, the obsession is not about the existence of the gay thoughts, but about the fear that enjoying their fantasy element means they are engaging in the reality of it.

This is very painful for heterosexual men who, to put it lightly, simply have a dick thing.  They are attracted to women, choose women for their relationships, but simply happen to find masculinity, and penises in particular, to be conceptually activating.  Maybe a penis is a narcissistic reminder of one’s own beauty, or maybe it represents control, power, submission, any number of things.  Maybe it represents freedom from having to always perform as the archetypal strongman in control.  Who knows.  In any case, it is not important.  What is important is to live in the present and allow yourself to value the things that are presently in your life.  If that means today you love being with your wife, but tomorrow you will spontaneously choose to be with a man, then deal with tomorrow when tomorrow comes.  Across all forms of OCD, the energy spent trying to sort out a thought in order to preempt it from creating a catastrophic future is nothing more than a mental compulsion.

Some may note that there appears to be slightly more acceptance of lesbian fantasizing in Western culture and media (note I said fantasizing, not necessarily practicing).  This may be because our patriarchal society promotes the fantasy of men with multiple women to pleasure them, so thinking of them pleasuring each other creates the implication that a man would be happily welcomed to join them.  It’s a chauvinist cultural flaw, but it exists nonetheless.  But women with HOCD tend not to allow this patriarchal loophole to give themselves permission to enjoy gay fantasy.  The OCD mind distorts the pleasurable thought into one being grotesque, sexless, and unlovable.  So the challenge of living with HOCD is both easier and harder as a woman because this perceived acceptance for straight women having gay fantasies can equate to a greater fear that being gay is a tangible truth.

All this being said, it is normal and healthy for straight people to sometimes have gay thoughts.  Whether or not these thoughts are enjoyed or hated is somewhat beside the point.  As a therapist specializing in Cognitive Behavioral Therapy, some beliefs will always seem inherently distorted to me.  The belief that simply having a gay thought and liking it makes you a gay person is one of these beliefs.  Remember, our lives are defined not by the content of our thoughts, but by the behaviors we seek when responding to them.

To read part one in our series of articles on HOCD, click here.

To read part two in our series of articles on HOCD, click here.

To read part three in our series of articles on HOCD, click here.

•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.  Jon can be contacted at jon@ocdla.com.

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Orthorexia – The Not-So-Healthy Obsession with “Healthy” Eating

Individuals suffering with Orthorexia exhibit symptoms similar to those of OCD and Eating Disorders.

Orthorexia Nervosa (also simply known as Orthorexia) is a relatively new term within the psychological and medical fields. Simply defined, Orthorexia is an eating disorder in which an individual has an excessive and ultimately unhealthy obsession about maintaining a diet that is totally “healthy” and “pure”. Because of their extremely restrictive eating, individuals with Orthorexia are often severely underweight, and frequently lack the proper nourishment to perform basic daily activities. Like most cases involving an eating disorder, the outcome of Orthorexia can be severe malnutrition and a significant reduction of one’s quality of life.

Orthorexia has not yet been accepted as a formal diagnosis by the psychiatric community, and has not been defined within the Diagnostic and Statistical Manual (DSM-IV). However, since first being described by Dr. Steven Bratman in 1996, many health professionals have observed the often debilitating results of this condition.

Symptoms of Orthorexia

Like Obsessive Compulsive Disorder, Orthorexia can be conceptualized as a constellation of obsessive thoughts and compulsive behaviors. The most prominent obsession seen in Orthorexia is an excessive concern about the healthfulness of food. Those with Orthorexia often spend many hours of the day planning and obsessing about what foods they have eaten or will eat, the nutritional content of that food, and how that food has been grown, processed, and/or prepared. Individuals with Orthorexia may obsess about any number of nutritional aspects of food, including, but not limited to the following:

• Calories
• Sugar (especially “refined” sugar)
• High fructose corn syrup
• Fat
• Hydrogenated or partially hydrogenated fat (trans fats)
• Protein
• Carbohydrates
• Glycemic index
• Salt / sodium
• Fiber
• Gluten
• Dairy products
• Fatty acids
• Vitamin and mineral content of the food
• Whether or not a food is “whole” or “organic”
• Whether or not a food is sufficiently vegan, vegetarian, or macrobiotic
• Whether or not a food is genetically modified

The most obvious behavioral symptom of Orthorexia is the compulsive avoidance of foods that the sufferer deems unhealthy or impure.  Individuals with Orthorexia may at first simply eliminate a few specific foods from their diet, but over time, their diets often become more and more restrictive. Eventually, they may eat only a select small number of foods that have been prepared in a manner that they have decided is “correct” or “pure”. At the same time, they may also purchase many expensive, “natural” or “organic” health food products and supplements that they perceive as more pure and/or healthy than traditional foods.

In addition to food avoidance, individuals with Orthorexia will often spend excessive amounts of time researching food issues related to the above concerns. This research may include many hours of internet searching, buying and reading an excessive amount of food, health, and nutrition related books, and near-constant examination of food labels when shopping for groceries at the market.

For individuals with Orthorexia, the obsessive concern with what goes into their bodies may also extend to other, non-food related health issues. Often, they have a disproportionate level of fear related to the possibility of exposure to what they perceive as pathogens in everyday products and in the environment. This may result in compulsive avoidance of certain soaps, shampoos, perfumes, and deodorants, as well as x-rays, vaccinations, or even mercury in dental fillings. They may broadly reject much of western medical science in favor of homeopathy, osteopathy, and other “complementary” and “alternative medicine” approaches.

It is also common for those with Orthorexia to spend much of their social time discussing food, and attempting to convince others of the “correct” way to eat. This may result in conflict with families and friends who do not agree with their views, and who take offense when the person with Orthorexia repeatedly criticizes their food choices. Likewise, those with Orthorexia may take offense when friends and family express their concerns about the health and dietary choices of the sufferer.

On a more internal, psychological level, those suffering with Orthorexia often experience significant guilt and shame when they do not maintain their purist dietary rules. They are usually extremely strict with themselves about their diet and their overall health, and are often overly judgmental towards themselves and their ability to control what they eat. Frequently, much of their self-esteem and sense of identity is rooted in their diet and in their success in satisfying their high levels of self-discipline.

Diagnosis and Relationship to Obsessive-Compulsive Disorder

While some see Orthorexia as an eating disorder, many mental health experts agree that it is best conceptualized as a hybrid of an eating disorder and Obsessive Compulsive Disorder (OCD). Like OCD, Orthorexia is defined by the individual’s obsessive thoughts (in this case, thoughts about certain foods being dangerously unhealthy), and the compulsive behaviors done in an effort to minimize the anxiety caused by those obsessive thoughts (in this case, food avoidance, as well as the other behaviors noted above).

The food avoidance seen in Orthorexia also has an obvious relationship to Anorexia. In fact, many with Orthorexia are eventually diagnosed with Anorexia as a result of weight loss related to their food avoidance. And some mental health clinicians see Orthorexia as a behavioral symptom of Anorexia in which the individual uses the issue of “healthfulness” as a justification for not eating.

It is also worth noting that some with Orthorexia will resort to purging behaviors similar to those seen in Bulimia in an effort to rid their bodies of impurities that they believe they may have ingested. Purging behaviors may include vomiting, use of laxatives and emetics, and use of colon cleansers to rid themselves of alleged toxins. Likewise, similar to those with Anorexia and Bulimia, individuals with Orthorexia often perform other compensatory behaviors such as compulsive exercising in an effort to make their bodies as perfect and pure as possible.

Symptoms of Orthorexia also overlap with those of other Obsessive Compulsive Spectrum Disorders. The excessive focus on “healthfulness” leads many to develop a distorted over-concern with their actual health, not unlike those with Hypochondria (also known as Health Anxiety). Likewise, many with Orthorexia have a distorted body image, much like those with Body Dysmorphic Disorder (BDD).

Because of the extreme restrictions commonly seen in this condition, it is often very difficult for those with Orthorexia to eat socially, or even be in social places at all. As result of trying to avoid being confronted about their food obsession, many with Orthorexia develop a pattern of social avoidance similar to that of Social Anxiety. The result is often a reduction in social interaction, and in some cases, a complete severing of friendships and relationships in order to maintain and protect their diet.

Finally, it is worth noting the overlap between phobias and Orthorexia. The two primary distinguishing features of phobias are the sufferer’s irrational fear of a specific object or event, and their subsequent efforts to avoid exposure to that object or event. Some conceptualize Orthorexia as essentially being a food phobia, in which the individual is terrified of being exposed to foods that they irrationally see as imminent threats to their well-being.

Click here to read part two of this series, which examines the treatment of Orthorexia utilizing Cognitive Behavioral Therapy, a.

•Kimberley Quinlan, 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, including Orthorexia.  She can be contacted kimberley@ocdla.com.

Thought suppression is a common feature of OCD, especially for those with Pure Obsessional OCD (sometimes called "Pure O")

Over the last few weeks, I have had a secret. For most people, this secret would not have been seen as important, but to me it was. Every time I had these thoughts I became overwhelmed with anxiety, fear and an almost palpable sense of terror. As soon as the thought of this secret flashed through my mind, I would have visions that would take me to its worst-case outcome.  As I played these thoughts out in my head, I physically experienced extreme anxiety, as if the discovery of my secret was actually happening.

Just a few days ago, I was on the treadmill and the thought flashed through my mind again. I was immediately plagued with heightened anxiety. Even the lady on the treadmill next to me noticed and commented that my face had a strange look on it. In response to the thought, I did what most people would do. I tried not to think about it.

At that point, I started a conversation with the lady next to me…and the thought popped up in my head. After the conversation was over, I read a trashy magazine… and the thought popped up in my head again. I then began running as fast as I could, dripping with sweat and breathing deeply, and the thought still managed to surface. Actually, not only did it surface, but it continued to inflate in my head, as if it was going to soon explode.

I got off the treadmill, and it was only then that I realized what I had been doing. I was trying to suppress an unwanted, intrusive, anxiety provoking thought. Even though I discuss this concept daily with my clients who suffer with Obsessive Compulsive Disorder (OCD) and anxiety, I had forgotten it for myself, and had spent over an hour trying to push away these scary thoughts instead of embracing them.

OCD and Clinical Studies on Thought Suppression

Thought suppression is a common feature seen in OCD, especially for those who suffer with what is sometimes called Pure Obsessional OCD, or “Pure O”.  But nobody wants to have anxiety provoking thoughts.  When we experience unwanted, distressing thoughts, we quite naturally respond by trying to control them, ignore them, or push them away. Unfortunately, many clinical studies have proven that trying to suppress unwanted thoughts usually results in the person experiencing the thoughts more often and in a more intense way. That was definitely the case for me.

The concept of “thought suppression” was first studied by Wegner, Schneider, Carter, and White in 1987.  In this study, a group of people were asked to not think about (or to suppress thoughts of) white bears for 5 minutes. During this time, participants were asked to verbalize their thoughts and ring a bell each time they thought about a white bear.  Following this initial 5-minute period, participants were then asked to purposely think about white bears for another 5-minute time period.  The results showed that participants reported thinking about white bears almost twice as often in the 5-minute period during which they were asked to not think about white bears.

If you suffer with intrusive thoughts, you may ask “Why doesn’t this happen with all of my thoughts?  Why is it that I always remember and I am always plagued by these intrusive thoughts, yet I can forget many of the items on my grocery list?”  The answer is simple - the items on your grocery list are not anxiety provoking, and you are not trying to forget them. The problem with trying to suppress unwanted, anxiety provoking thoughts is that the more effort you put into forgetting these thoughts, the more likely you are to be unable to forget them.

Treating Intrusive OCD Thoughts

So, if you have ever experienced the angst of unwanted, intrusive thoughts…or if you are curious about my secret, you might be wondering “How can I get those horrible thoughts out of my head?” or “How did she get those thoughts to go away?”.

The most effective approach to take in managing intrusive, unwanted thoughts is Cognitive Behavioral Therapy (CBT).  And the most basic tool in CBT is what is commonly known as Cognitive Restructuring, in which a person with an unwanted thought briefly and objectively reviews the thought.  For example, when I stopped to look at my secret thought, I immediately realized that it was neither rational nor realistic.  I identified it as such, and assigned it an alternative thought that I could use to challenge the thought when it next arose.

Unfortunately, for those with OCD, Cognitive Restructuring can quickly become a compulsion in itself.  We have treated many people who are unable to get the benefits of Cognitive Restructuring because they quickly resort to compulsively analyzing their thoughts (and the alternative thoughts they come up with to challenge their unwanted thoughts) in an attempt to control them.

For this reason, a different approach is needed.  When faced with intrusive, unwanted, anxiety provoking thoughts, the most effective long-term cognitive tool is what is commonly called “mindfulness”.   From a mindfulness perspective, when one experiences intrusive, unwanted, anxiety provoking thoughts, the goal is not to attempt to reject them or or push them away, but rather to allow and accept their presence in your mind – to have a more open and peaceful relationship with them.  This doesn’t mean that you need to enjoy the thoughts or accept the legitimacy of their content.  It merely means that you accept reality as it is…and reality is that these thoughts are in your head.  Think of it as being similar to accepting a rainy day when you had planned to go to the beach – you may not like the rain, but you will be a lot happier accepting it and getting on with your day than you will be if you get angry at the rain for existing.

The most important component in managing unwanted thoughts is changing one’s behavioral response to these thoughts.  People with OCD often try to control and/or avoid their anxiety-provoking thoughts.  Unfortunately, as noted above, this only results in having more of the same thoughts.

While it may seem counter-intuitive, the most effective behavioral response to unwanted thoughts is to allow them to exist while making no effort whatsoever to control or change them.  In fact, if you really want to  challenge  these thoughts, the best approach is to purposely choose to have them.  If you do this, you will soon discover that you have de-fanged these thoughts.  You may still have these thoughts – after all, many people, including those without OCD have similar thoughts – but you will care far less about them.  They are, after all, just thoughts

So how did I deal with my “secret”?  Using the above techniques, I accepted that the thought was not that important and that it did not require such a heightened and lengthy response. I accepted that this thought is no more important than most of the thoughts I have on any given day, such as “what color shirt shall I wear” or “what will I have for lunch” or “should I  shower before or after dinner”.  The most important thing to remember is that suppressing the thought will only make it stronger. Avoidance will almost certainly not make the thought go away.

I am assuming the fact that you have read this far means that either a) you have experienced the distress and aggravation of failed attempts to use thought suppression, or b) you are still waiting to learn what my secret was.  If you are among the first group and are experiencing unwanted thoughts, please don’t hesitate to contact us so we can help you learn the tools to manage your intrusive thoughts. And if you are among the latter group and are still hanging on to hear the juiciness of my secret, read the last paragraph again – the secret and the thoughts were not important!

•Kimberley Quinlan, 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.  She can be contacted kimberley@ocdla.com.

Jon Hershfield of the OCD Center of Los Angeles discusses treatment of Sexual Orientation OCD, also known as HOCD or Gay OCD, using Cognitive Behavioral Therapy (CBT) and Mindfulness.  Part three of an ongoing series.

There are many variations and sub-types of Sexual Orientation OCD (HOCD)

When I initially wrote the part one and part two of my article on Sexual Orientation OCD (aka “Homosexual OCD”, aka “HOCD”, aka “Gay OCD”), it was intended solely to reflect this rather common form of the disorder as I saw it presented in several of my clients.  I had not anticipated such a significant online response, with so many additional questions and angles on the subject.

Sexual obsessions in general are under-reported because of shameful feelings associated with them.  And yet there is probably a somewhat higher prevalence of sexual obsessions in OCD than any other obsession for this same reason – the thoughts are unwanted! This seems so very evident in Sexual Orientation OCD because the feared consequence appears so tangible.  In other common OCD obsessions, such as “Harm OCD”, the idea that someone might be in denial of violent impulses is plenty terrifying.  However, there is an understanding that being violent is unacceptable in and of itself.  With Sexual Orientation OCD, the sufferer generally does not see anything wrong with being gay per se, as long as it is not themselves being gay.  This causes a lot of confusion and a lot of resistance to seeking treatment.

I’d like to use this latest installment in what has become a series of discussions on Sexual Orientation OCD to be more specific about the different ways I have seen this OCD manifestation present and the different Cognitive Behavioral Therapy (CBT) strategies that appear to work.  I have attempted to categorize them, but it’s important to remember that sufferers are likely to fall into a combination of several categories and not just one.  Also bear in mind that I will continue to use “gay” or “homosexual” to be synonymous with alternative orientations for simplicity’s sake only.  Homosexual and bisexual individuals with OCD can, and do, sometimes obsess about being straight.

All-Or-Nothing HOCD

This is perhaps both the most common and the least reported subtype of HOCD because it is easy to overlook the OCD characteristics.  In short, All-Or-Nothing HOCD describes the experience of those who have always been of one orientation, have never experimented with other orientations, and who do not have gay fantasies, but who just randomly have a “gay” thought or feeling one day and it scares them.  It is often reported as starting with a simple, “Did I find that person attractive?” and “What does it mean that I can’t be 100% certain that I did not find that person attractive?”

In All-Or-Nothing HOCD, the primary distorted belief is that straight people never have any gay thoughts, so any gay thoughts must be an indicator of latent homosexuality.  In fact straight people do have gay thoughts, but generally prefer not to apply them to gay sexual behaviors.  In actuality, it is not possible to know what the word “gay” even means on a literal level without having what can only be described as a “gay” thought.

So for the sufferer who sees gay thoughts as contaminating an otherwise purely straight mind, compulsions are going to be focused on making the gay thoughts go away through various proving rituals.  This may take the form of compulsive masturbation to straight fantasies or avoidance of anything that might trigger the presence of a gay thought.  It often involves avoiding people who the sufferer sees as even having the potential to be gay.  Just as a handwasher tries to be certain there is not contaminant on their hands, this HOCD sufferer is aiming for total eradication of the unapproved gay thought.

Cognitive Behavioral Therapy (CBT) treatment strategies for All-Or-Nothing HOCD should involve gradual exposure to things that trigger gay thoughts while the sufferer practices resisting the urge to tell themselves they are not gay.

Relationship HOCD

People are complicated.  That means relationships are twice as complicated.  Some people are lucky in love, some people are unlucky, some people are both, and some people really can’t tell because of their OCD.  This form of  HOCD occurs when an OCD sufferer uses potential gayness as an explanation for what they see as failed heterosexual relationships.  Women with Relationship HOCD may identify themselves as “man-hating dykes”, while men may see themselves as “just not understanding women”, and may describe themselves as being “in denial” of their “true” sexual orientation.

Often in cases like these, the HOCD itself is a smokescreen for what is sometimes called Relationship OCD (aka ROCD) or Relationship Substantiation OCD.  Those with ROCD tend to have obsessions that revolve around fears of not “really” loving or being sexually attracted to their spouse or partner, not being involved with the right person, or not being the right person for their partner.  Those with Relationship HOCD can put off dealing with these issues if they conceptualize themselves as being incapable of having a healthy heterosexual relationship because, in their mind, they might actually be gay!

Because this form of HOCD emphasizes partnership, sufferers are likely to over-attend to how they relate to people of the same sex.  A man may notice that he feels better understood, has more in common with, and enjoys his time with another man in ways that women do not satisfy him.  The only thing missing is the sex, he thinks, and this triggers a lot of compulsive analysis about who he is “really” wired to love.

Similarly, a woman may become aware that other women share qualities their male partners seem to lack – for example, sensitivity, patience, and emotional availability.  In those who don’t have HOCD, this same-sex identification is looked at as totally normal.  “Of course my same-sex friends understand where I’m coming from.  They know what the other sex is like!  They get my interests and motivations!”.  The word “gay” doesn’t enter into the equation.

CBT for Relationship HOCD is going to involve traditional Exposure and Response Prevention (ERP) for sexual orientation fears, but also exposure to behaviors that demonstrate vulnerability to a romantic partner, accepting uncertainty about the “quality” or “completeness” of heterosexual relationships, and other non-avoidance exposures.

Self-Hating HOCD

This form of HOCD generally has more to do with depression than sex or sexual orientation.  Typically (though not exclusively) this seems to occur in people who were severely mistreated, abused, or bullied.  Just as this can occur in Social Anxiety Disorder, the “bully” takes up residence in the person’s mind and any perceived failure in life triggers an internal statement of “You’re gay.”  It’s meant as an insult, more than a suggestion that one should set about finding themselves sexually.

The constant inner-abuse seen in this type of HOCD often leads to a deeper depression, which further distorts the intrusive thoughts, which in turn leads to even more depression.  In some cases this may lead to a pseudo-gay fantasy state in which the sufferer imagines themselves living out what they see as the greatest disappointment to their parents.  The line of thinking is that they are so unlovable as to be invisible to their desired orientation.  In treating those with this type of HOCD, there may be more emphasis on cognitive restructuring and learning to identify “bully” thoughts as distorted glitches in the mind which are essentially irrelevant to sexuality.  Because ERP requires significant motivation and commitment, it may also be clinically appropriate to focus on the depression first before engaging in exposures.

Experimental History HOCD

Despite the fact that same-sex exploration is common in children who are learning about the human body (i.e. playing “doctor”) and discovering how different things look and feel, people with OCD who obsess about their sexual orientation may use benign childhood experiences as “proof” of latent homosexuality.  So despite a post-pubescent life of heterosexual behavior, the presence of unwanted homosexual thoughts triggers frightening doubts.  The sufferer is likely to compulsively review childhood memories and the unknowable memories of thoughts and feelings that might have been had during any same-sex exploration.  “What exactly did I do and why?”

It is also common for teenagers throughout the course of puberty to experience confusion related to gender, orientation, and other sexual issues.  As the sexual brain develops, so too the does the sexual mind.  For people with OCD during their teens, this can be very troubling.  For those whose HOCD develops later, they may look back on this period in which their sexuality was developing and compulsively analyze anything that could be construed as inconsistent with their current sexual preference.

Another variation on this reflecting form of HOCD is compulsive analysis of any same-sex play that might have taken place in college or at some other point in life.  A big part of treatment for those with this type of HOCD is identifying mental checking as a compulsion to be resisted, instead of as a way to figure out one’s sexuality.  Curiosity is not orientation.  Whatever happened, happened.

Real Man / Real Woman HOCD

People who suffer from this form of OCD place a lot of emphasis on masculinity and femininity and the cultural expectations that come with them.  A male sufferer might notice an attractive male, and then chastise himself for being able to notice attractiveness in males.  He assumes this is a sign of femininity, something a “real man” would have no ounce of (again see the all-or-nothing thinking).  This can also present itself through a man’s affinity for the arts or other things he may have been culturally primed to see as non-masculine.

Cognitive Behavioral Therapy (CBT) for this form of HOCD may involve more exposure to material that the sufferer sees as “dainty” or weak, such as watching program with a flamboyant homosexual character or attending a ballet.  This is sometimes more triggering than exposure to gay pornography.

Similarly, a heterosexual woman may notice another woman is beautiful and then distort this through the belief that “real women” only ever think about men.  It also may involve avoidance of assertive behavior or any other cultural attribute traditionally associated with masculinity.  Exposure for this sufferer may involve images and films involving “butch” lesbians or feminist literature.

Groinal Response HOCD

The functioning paradigm here is, “I must experience sexual arousal or groinal sensations only in very specific pre-approved circumstances.”  These circumstances typically mean in the presence of an attractive, age-appropriate member of the opposite sex.  But there are a few important considerations to note here:

• all sexual thoughts (wanted or unwanted) may cause sexual arousal;
• attending to one’s groin actually causes sensations to occur there;
• there are sensations going on in your groin all the time, but unless you go out of your way to pay attention to them, you just don’t notice them;
• groinal sensations often occur for no reason.

Men don’t get headaches just because they thought of something painful and they don’t get erections just because they are feeling sexual.  In short, who knows what’s going on down there?  Yet the HOCD sufferer is going to compulsively check and analyze sensations for evidence of homosexuality.  Part of the confusion the OCD capitalizes on is the fact that groinal stimulation is generally considered a positive sensation.  Fellatio or cunnilingus is going to feel good no matter what gender is delivering it, but the HOCD mind insists it only be delivered by a person to whom we are attracted in order to accept it.  HOCD manipulates the mind into thinking that any positive groinal sensation at the “wrong” time must mean a general sexual preference to whatever is in the environment at that moment.

Cognitive Behavioral Therapy(CBT) for the treatment of this type of HOCD is going to involve identifying and challenging distorted beliefs about groinal responses and exposure to arousing material that falls outside of their traditional preferences.

Spectrum HOCD

Not everyone agrees, but many believe as Alfred Kinsey did, that sexuality exists on a scale with straight on one side, gay on the other, and people mostly somewhere in the middle.  While it will no doubt be triggering for some readers to consider, many people who identify as heterosexual sometimes have homosexual thoughts, feelings, sensations and fantasies.  Those without obsessive-compulsive tendencies allow themselves to enjoy this aspect of their reality.  These are people who prefer sexual activity with the opposite sex, but also find same-sex fantasies (and even behaviors) to be somewhat intriguing and arousing.  They are not bisexuals, who would likely say they are quite capable of sexual and romantic fulfillment with either sex, but are instead heterosexuals who simply are not dangling off either edge of the Kinsey scale.

For those people who experience themselves as somewhere within this spectrum of sexuality, but also have HOCD, this can be very upsetting.  They will want to know for sure if they are bisexual or not, how far in one direction or another they “belong”, and what the “right” term is to describe themselves.  “Am I 10% gay?  20%?  If I don’t know for sure, then I will always feel that I am harboring a secret.”  Without an appropriate label, they live in constant fear of an identity crisis.

Treatment for this type of HOCD relies heavily on Mindfulness Based CBT and resisting compulsive mental analysis.  The exposure is not aimed at homosexuality, but at uncertainty.  This can sometimes be done in the form of an imaginal exposure script in which the sufferer describes the negative consequences of never knowing what to label themselves.

(Really) Need-To-Know HOCD

These are people who identify as heterosexual but have been struggling with untreated (or mistreated) HOCD to such an extent that they have gone from mental checking, to physical checking, to actual experimental checking.  This is somewhat rare and I would imagine some people might read this and say, “OK, let’s just call it gay then,” but that’s not what is happening here.  People who suffer from OCD, regardless of the manifestation, are struggling against an intolerance for uncertainty.  People without OCD largely tolerate uncertainty by not paying much attention to it.

For any reader who does not have OCD, try thinking really hard about the fact that you are not 100% certain what will happen when you die.  Now imagine that all of the people you love will consider you hugely irresponsible for not attaining certainty on the issue.  This is how an OCD sufferer often feels.  Not only do they poorly estimate the risk posed by unwanted thoughts and feelings, but they have an exaggerated sense of responsibility for avoiding these risks.

Ultimately, for some HOCD sufferers, being gay may sound like a relief from not knowing for sure that they are straight.  So they begin to build a case for gayness.  This may involve seeking treatment from LGBT specialists, trying to train themselves to enjoy gay pornography and sometimes engaging in sexual experimentation.  The goal is not necessarily to like gay sex, but to determine once and for all – “am I gay or straight?”.

Typically this backfires in one of two ways.  Either the person finds the experience somewhat satisfactory but not preferential to straight sex, or they find the experience abhorrent and resent themselves for having done it.  In either case, they are left with the same uncertainty they find intolerable, plus more ammunition for the OCD.  Just as in the other forms of HOCD, the objective has to be tolerance for not-knowing rather than proof.

These are the various subtypes and angles on HOCD that I have treated thus far, but there are certainly others.  In the next installment of this series, we will examine some additional nuances to HOCD and common impediments to effective treatment.

To read part one in our series of articles on HOCD, click here.

To read part two in our series of articles on HOCD, click here.

To read part four in our series of articles on HOCD, click here.

•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.  Jon can be contacted at jon@ocdla.com.

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