Demystifying OCD: Beyond Cleaning and Checking - An Insightful Guide

In this two part episode, Dr. Amy Young and I discuss the spectrum of Obsessive Compulsive Disorder and adolescents.

In this first episode, we shatter some stereotypes and myths of OCD. Prepare to deeper understand the nuanced and often misunderstood world of OCD with our expert guest. Together, we're lifting the veil on OCD, going far beyond the simplistic view of just cleaning and checking, bringing to light the realities of both overt and covert compulsions. We'll also tackle the mental weight of OCD, discussing how it can manifest through actions such as constant body scans, seeking reassurance, and incessant rumination. Prepare yourself for a revelation on the "intolerance of uncertainty", and how this can lead to obsessions around delicate topics like one's sexual orientation.

Professionals and casual listeners alike will find our discussion on treatment strategies intriguing. Not all approaches are created equal, and some can even be more harmful than beneficial. We delve into the art of navigating the youthful need for certainty and encouraging age-appropriate risks. The importance of recognizing OCD amidst other anxiety and depression disorders is also brought to the forefront as we discuss the potential dangers of co-compulsing. Lastly, don't miss our in-depth discussion on Exposure and Response Prevention, a unique method of treatment that involves tiny steps and gradual progression towards more challenging tasks. Whether you're a sufferer, a caregiver, or a curious listener, this episode is sure to provide a wealth of insights into the world of OCD.

Keep an eye out for the follow up episode next week!!

Bio:
Dr. Amy Young is the Founder and Director of the CBT Center for Anxiety & OCD and has been working in the behavioral health field since 1995. She completed her Postdoctoral Fellowship training under nationally recognized OCD expert, Dr. Jonathan Grayson, and anxiety expert, Dr. Linda Welsh. She holds Doctoral and Masters degrees from Philadelphia College of Osteopathic Medicine, a Clinical Psychology program specializing in Cognitive Behavioral Therapy.

 Dr. Young treats all types of anxiety, OCD and Obsessive-Compulsive related conditions in children, teens and adults. Dr. Young utilizes a variety of CBT interventions, including Exposure and Response Prevention, among other evidence-based treatment.

Transcript

Speaker 1: 0:02

Hi, amy, welcome to the podcast, thank you so much for having me. Yeah, I'm so excited to talk to you about OCD and sort of the different things that lie within the spectrum of OCD, if you will. But before we get into sort of the nitty gritty of things, could we talk a little bit about how you got into this field, into sort of maybe specifically in terms of OCD?

Speaker 2: 0:37

Absolutely so. I was a pediatric generalist for many years and wound up doing a postdoctoral fellowship at a practice that specialized in anxiety and OCD and related conditions and I stayed on with that practice for eight years. I really fell in love with the population and it wasn't really a plan. I just sort of thought it would be nice to have a subspecialty and I absolutely fell in love with it and just never look back.

Speaker 1: 1:13

Yeah, and this is such an interesting field because we talk a lot about sort of behaviors, especially when it comes to anxiety, depression, grief even, but somehow OCD is not kind of brought up, and I don't know if it's just in my experience, or a lot of times parents especially will sort of not kind of even talk about OCD. I don't know. It kind of has sort of this, maybe a fear factor, I'm not sure. Do you see that in your practice?

Speaker 2: 1:56

I think that OCD can definitely be an interesting condition in that sometimes we find it's a very misunderstood condition. Sometimes people will misuse the terminology and they'll throw it around. You know, I'm so OCD, which is really demeaning to people who are experiencing severe and debilitating OCD and suffering with it and at the same time, because it's so misunderstood, there are times when people may not understand that it's OCD, that what they're dealing with is actually OCD, because even among professionals there isn't a lot of good information that is exchanged. So I think it's a condition that's greatly misunderstood.

Speaker 1: 2:47

And so can you speak a little bit to what is sort of this misunderstanding or misconceptions of OCD.

Speaker 2: 2:58

Yeah. So I think one of the main misconceptions is that OCD is just cleaning or checking, and while those can be components fears of germs and contamination or concerns that something has been left undone there are a whole host of other manifestations and many of the compulsions can occur as mental compulsions. So individuals can really experience a lot of difficult, intrusive thoughts which are called obsessions, and then the compulsions can be what we call covert or mental compulsions. So parents may not be able to see some of the compulsions that their teenager is engaging in rethinking things, neutralizing, trying to reassure themselves, maybe avoidance, and so I think that that can make it really confusing and misunderstood.

Speaker 1: 4:00

Yeah, so on one hand, what I'm hearing you say is that in many ways OCD especially, I think, through media has become sort of this frivolous term that we all kind of throw around oh, I have OCD because I cleaned my flows twice this week, or you know and on the other hand, we are also kind of not really understanding what those behaviors or those compulsions could be or are. So, in keeping with that sort of line of thinking, can you elaborate a little bit on the mental compulsions, because that is something that we don't see. And so the intrusive thoughts, the obsessive thoughts are they about anything specific or are they about everything?

Speaker 2: 4:57

Sure. So really the hallmark that something is OCD and what can differentiate it from other kinds of OCD, is what is called the intolerance of uncertainty, so feeling that I need to be certain about something, and that can show up in lots of different ways. So one of the ways that a person may attempt to get certainty and the illusion of certainty because certainty really doesn't exist but in a way to try to achieve that illusion of uncertainty or of certainty, individuals may engage in a number of mental compulsions. They can be reassuring themselves, it can be neutralizing things, it can be thinking about things over and over again. It can be replacing a quote, unquote bad thought with a good thought. It can even be a mental compulsion of trying to figure things out, which can be very difficult sometimes to figure out because it's so subtle and it may seem like the kind of behavior that you would want to engage in, trying to figure things out. But in actuality they are mental compulsions. They're repetitive in pursuit of certainty, and engaging in them frequently actually only leads to more distress.

Speaker 1: 6:25

Yeah, and I can definitely see that even sort of in our negative thought patterns, where it's sort of bringing up anxiety, it's bringing up stress and then you kind of fall into that loop of negative thought patterns. Could you perhaps give an example of mental compulsion, if possible?

Speaker 2: 6:54

Absolutely so. A presentation that may be less known that that can occur for teenagers is what's called sexual orientation OCD. So this can be for a person who just really has a difficult time not knowing for certain what their sexual orientation is. They may be a person who has some sense of their heterosexual identity I'm heterosexual, I'm gay but they just feel this nagging uncertainty, and one that goes beyond just normal questioning that teenagers may do. They just feel like I need to know, I need to know for certain, and they're engaging in a lot of things. So, for example, in that situation they may be engaging in compulsions of checking in with their parents, seeking reassurance, maybe checking things, doing tests online.

Speaker 2: 7:55

Those might be some overt compulsions, but some covert or mental compulsions are things like body scans, For example. If they're with one of their peers that is a trigger, somebody, that kind of triggers that worry about their sexuality. They may be scanning their body for signs of any kind of arousal to see. Does that mean I'm attracted to my friend? They might be mulling it over in their mind. I noticed my friend and they're attractive.

Speaker 2: 8:28

I noticed what their body looks like If we were at the pool or the beach or changing in the locker room. What does this mean about me? What does this mean about my sexuality? What does this mean about my feelings for my friend? And they continue to have those intrusive thoughts and engaging in those mental compulsions, thinking about it over and over again. We can also see avoidance in that situation, not wanting to be in those triggering situations and attempting to avoid things that might actually be congruent with their values, might actually bring them pleasure and joy, like going to see a movie with a friend or going to the beach or the pool with a friend.

Speaker 1: 9:15

Yeah, thank you for that. That really sort of explains a lot of what those intrusive thoughts can be based in, which also sounds like, once they have a doubt or they're uncertain about something, that it's kind of mulling over and going over that obsessively and compulsively. You talked about a couple of things, but I'm going to sort of focus on sexual orientation for a minute and then go back, go to reassurance and avoidance. Developmentally, I can see how sexual identity is such sort of an emerging thing around sort of late not late, sorry, but you know sort of preteen teen years. Is that where you also in your sort of practiced and understanding and study of OCD? Do you see that that's where these compulsions and behaviors emerge most likely? Or do we also see them at a younger age?

Speaker 2: 10:30

Sure. So we can see them at really just about any age. There are times when they're more common. We may see them for preteens and teens emerge, you know, with with greater frequency. But we can certainly see OCD behaviors and symptoms, you know, even sometimes in children as young as three or four or five. They do tend to be more likely to be linked to what we call our vulnerable self as we get older.

Speaker 2: 11:06

So things that might upset us more or trigger us more or be upsetting to us at that developmental time we can see with greater prevalence. So, for example, with children, as they begin to have the capacity for more abstract thinking, they can have some intrusive existential anxieties. What if my parents aren't real? What if I'm not real? What happens when we die? What if I die? So, you know, someone who's three or four may not have the capacity for that kind of intrusive thought because they don't have that kind of abstract reasoning. But as we get older, and oftentimes, because individuals with OCD tend to be smart and gifted and creative, they may trip across some of those developmentally normative questions even earlier, you know, than their peers, whereas most likely someone who is a child wouldn't have intrusive thoughts of you know regarding their sexuality. You can see, for example, developmentally normative, vulnerable self triggers coming out. Maybe a child who is a really it's important to be a good person.

Speaker 2: 12:30

That's really important in their family that we're good people. Ocd will capitalize on that value and on that vulnerable self-theme and give have a certain intrusive thoughts that get hooked about. What if you're not? What if you're not a good person? What if you're capable of hurting someone? A really classic presentation might be a harm OCD. Maybe a child who's using scissors or a knife, maybe they're using scissors at school and they'll get an intrusive thought what's to stop me from harming someone? And again I want to be clear that these are what we call ego-distanic thoughts. They're not thoughts that the person wants to engage in. In fact, far from the opposite, it's the least likely thing that they would want to do or are capable of doing. But OCD really capitalizes on that and says but what if so? It so the developmentally normative experiences that we have, the ability to have a sense as to who we are as it relates to other people, the ability to have impulse control, various components of our identity are developing.

Speaker 1: 13:44

Ocd really capitalizes on those moments and I'm hearing you say OCD capitalizes right so as so, if I understand correctly, it's OCD is something else, not you and so there is that distinction between self and the behavior. Could you talk a little bit to that so that our listeners, parents, sort of understand what that means and where you know sort of that stands?

Speaker 2: 14:17

Yeah, so there are some helpful strategies that we use, particularly when we're working with children and adolescents. Two of those strategies are called externalizing and personifying. So when we personify and externalize OCD, what we do is we see it as something separate from ourselves. So sometimes we'll encourage teens to give it a name.

Speaker 2: 14:45

You know the worry monster, mr Bossy pants, bob, you know Mr Perfect, mrs, symmetry, whatever we want to, all kinds of creative things. And then what we do is, as a therapist, we team up with the teenager, their parents if appropriate, to have them involved in the treatment, and it's really all of us against OCD. We're teaming up against this externalized and personified symptoms and that can be really really helpful as seeing it as something separate from us that we have agency over, that we have internal locus of control over. And to also really bring home this message that the compulsions are a choice is also really important. It doesn't feel like a choice, but that's our job in therapy is to help our teenager see that the choice to engage in either physical or mental compulsions it is in their hands and to give them a greater sense of agency with that.

Speaker 1: 15:57

Yeah, that's so helpful in understanding how sort of the self is a separate entity from OCD and that you have some sort of control or choice in that. And especially for teenagers who feel like they rarely have control over so much in their life, that can be an empowering way to see something that seems to be out of their control. I want to go back a little bit to reassurance and avoidance, especially avoidance, because in many ways that also sounds to me like anxiety, right, Like when it comes to anxiety, we avoid, we don't want to do those things, and uncertainty and sort of this thing that is unknown right beyond us To me sounds a lot like anxiety. Could you talk a little bit to the difference between sort of anxiety related disorders and OCD?

Speaker 2: 17:18

Sure, yeah, so there definitely can be a lot of overlap between the two in terms of symptoms and tendencies. However, I would say one of the biggest things that I look for as a therapist to differentiate the two is is there this intolerance of uncertainty? Is the teenager really wed to this idea? That? I need to know, I need to be certain, I have to know for sure. I can't have any doubts about this, because if that's the case, that they feel this overwhelming sense of needing to be sure that that is a therapist tells me that we may be talking about OCD.

Speaker 2: 18:03

And a second way is that some of our typical strategies, treatment strategies that we would use for anxiety, they may not work for OCD and in fact, sometimes some of the strategies that we use to treat anxiety may actually not only be not helpful for OCD, but there are times when they may be harmful, they may actually detract from treatment.

Speaker 2: 18:30

So, for example, different kinds of cognitive therapy trying to reassure the person or tell them it's not true, or looking at the likelihoods or possibilities While those strategies may be helpful for other kinds of anxiety and it you may get some traction and the person is able to move forward, that may not be the case for OCD and in fact sometimes when we're trying to provide that kind of reassurance or looking at probabilities or possibilities, we may actually be engaging in a behavior that's called co-compulsing.

Speaker 2: 19:06

So that's when we as parents or therapists are actually participating in a compulsion with the teenager. So providing a lot of reassurance about something you're such a good person, I know you would never hurt anyone, you're the least likely to hurt anyone, you know. Let me talk to the teacher about you know you're not having to use scissors and art class. You know all those kinds of things. They seem very well intended and helpful but in fact, you know, ocd is a condition where if you give it an inch, it tends to take a mile. So the more that you try to give the person a sense of certainty at times, the bigger OCD can grow.

Speaker 1: 19:54

So in that sense reassurance also does not work. Yeah, yeah that's so.

Speaker 2: 20:00

You kind of will know as a parent or as a therapist, you'll know that it's not working when you see that that the teenager is not improving in the long run with that reassurance. So they may get, they may feel a little better and seem a little better in the short run. But if you find that they keep asking the same question, even if it's asked in different ways, but they keep asking the same question, there's still that same fear consequence that they're concerned about. That you know you're probably looking more at OCD versus other kinds of anxiety conditions.

Speaker 1: 20:35

So I'm wondering if reassuring and, of course, avoidance sort of does not work. What is the measurements? Measurement, if you will, of I don't know if I can even say this sort of like getting over OCD, if you will, and I'm not sure if that even. Am I saying that right, like what? What is, what is the degree of measurement, if you will?

Speaker 2: 21:07

Sure so, because OCD, out of all the anxiety spectrum conditions, tends to be the most biological or genetic in etiology or root.

Speaker 2: 21:19

We will often say that OCD is not a curable condition but rather a treatable condition. So if a person has a propensity or a desire for certainty, chances are that that tendency will continue, that they may still have that desire for certainty. But what we want to teach the person to do through treatment is to navigate around that desire for certainty in different ways where they don't feel like the only strategy that they can use is to give in to OCD to do what it asks to try to get certainty. But in fact we want to actually teach the person how to be okay without having certainty. We want to teach the person to be able to take some really value oriented, developmentally appropriate risks in their life. We want them, through experience of exposure therapy, to be able to see that things get easier over time when we do the opposite of what OCD tells us to do, that we see that we can handle it over time and we see that we can learn something as a result of doing the exposure work.

Speaker 1: 22:36

Yeah, and I think that's such an important distinguisher and I'm really sort of excited to hear that, almost because a lot of times when we even with anxiety, depression, a lot of times parents will say well, you know, they've been working for such a long time with this, why aren't they over it or why aren't they cured of this disorder? And so to know that OCD is a treatable disorder and perhaps not curable is kind of a good to know kind of a thing, especially because we are always in that sort of mode of okay, let me move beyond this, let me get over it.

Speaker 2: 23:28

I would also argue as an anxiety and OCD specialist that potentially, if a teenager is being treated for anxiety and they're not getting traction and treatment just really doesn't seem like things are improving over time in a way that we'd like them to, the significant possibility exists that there may be some elements of OCD involved in that, that there may be a higher rate of this cognitive distortion, this kind of stinking thinking of.

Speaker 2: 23:59

I need to be certain and I think that that's really important and something that we talk a lot about in our staff trainings is that even if we think that a condition might be social anxiety or it might be generalized anxiety disorder and we're not getting the traction that we want in treatment, it might be because there are some elements of OCD in there, some traits in there, maybe some perfectionism, where the person just feels this need to know, they need the certainty, maybe about a social situation, in which case then using some OCD strategies could be really helpful and again, leaning into being okay, not knowing, and and I would argue that having that strategy and having that skill honestly for anyone is so helpful. You know, we obviously live in very uncertain times and teenagers are growing up in very uncertain times, and so, in general, being able to have some tools that help them navigate uncertainty in general because life is full of it, I would argue is those are tools that I wish every person had in their toolbox.

Speaker 1: 25:21

Yeah, yeah, absolutely so. In that sense, what are some of the treatments that are available for OCD?

Speaker 2: 25:32

Sure. So there's a number of different kinds of treatments. The most evidence-based and commonly used treatment is what's called exposure and response prevention, or ERP. It's a type of cognitive behavioral therapy and essentially what it involves is our two components. One is the exposure, and that is essentially doing things out of the person's comfort zone, little by little, through what we call graded exposure. So we basically take some baby steps, we start with easier things, work our way to more difficult things, and we do it in repeated fashion. So we do it over and over again and we do it in a prolonged fashion. So we do it and we kind of stick with it so that we can maybe see that the anxiety level comes down as we do those things that are difficult.

Speaker 2: 26:27

And or maybe we see that, like we can handle it. Maybe we see that the bad thing that we were afraid of having happened, maybe we you know it didn't happen. Or maybe the bad thing that we're afraid would happen happened but we saw that we could handle it, you know. So it's a win-win either way. And then the second part of the treatment is what's called response prevention or ritual prevention, and that part involves essentially not doing the things that the person might typically do in order to relieve themselves of the anxiety. So, going back to those compulsions we were talking about those physical things, checking things, seeking reassurance, clarifying those mental compulsions, neutralizing body scans, mulling things over in our head, all of those things. We want to get a really good, hearty list of all that they are and then we want to slowly work to reduce and eliminate those behaviors.

Speaker 1: 27:34

Thank you for that. Okay, so I'm going to actually stop here and then piece the other together, because we talked about resources for parents, so let me just do 2750. Okay, okay, that's so I'm going to stop here.