Understanding OCD Traits and Using Exposure Response Prevention (ERP) Therapy

Many of us have made a casual comment about obsessive-compulsive disorder, as in, "I'm so OCD about washing vegetables." But for those who suffer from the disorder, obsessions—like a fear of germs—and compulsions—like repeated disinfecting—can be debilitating. OCD may be especially challenging at a time like during the pandemic when public health messages intended to protect us from COVID-19 can reinforce germophobia. These well-intended messages could also amplify feelings of uncertainty, a component of the illness.

"Studies are underway to determine how difficult the pandemic has been for those with OCD, but it's safe to say that some people with the disorder are really struggling right now," says Elna Yadin, PhD, the director of the OCD Clinic at the Center for Treatment and Study of Anxiety.

What Is Obsessive-compulsive Disorder

Does that mean that if you've become fanatical about sanitizing, you have obsessive-compulsive disorder? No. "OCD is an anxiety disorder that causes intense distress," Yadin explains. "Obsessions are intrusive, unwanted, relentless thoughts or urges that can cause fear, guilt, distress, or disgust. And in an effort to get rid of or neutralize those upsetting thoughts, a sufferer develops compulsive behaviors."

The disorder, which is estimated to affect one in every 100 adults in the U.S.—equally between males and females—can come on at any time. However, it frequently occurs after a traumatic or stressful event and tends to hit in the preteen years or in early adulthood.

A number of genes have been linked to the disorder. So, you can inherit a predisposition for OCD. If a parent has it, there's about a one in four chance their child will, too.

Because doctors often don't recognize the condition and sufferers tend to hide their symptoms, it typically takes 15 years or more for those in need to get help. This delay in treatment is a shame since OCD can interfere with—or even debilitate—a person's ability to function. The good news is that treatment can ease the disorder's grip and transform people's lives.

Compulsions On Repeat

When you think about OCD, you might imagine someone whose hands are raw from excessive washing. But the disorder isn't about cleanliness. It's about unwanted thoughts. And the fear of germs is just one of the hundreds of disruptive thoughts that torment those affected with OCD, says Jonathan Grayson, PhD, director of the Grayson LA Treatment Center for Anxiety & OCD in Pasadena, California. "Obsessions include everything from worry that you left the stove on to fears that you might kill someone you love. They're limited only by people's imaginations, and people with OCD tend to be extremely creative and intelligent," says Grayson.

Other common obsessions include:

• Perverse sexual thoughts
• Fear of blurting out an obscenity
• Concern with offending God
• Superstitions about colors or numbers

"Many of us have passing scary thoughts, but we're able to realize they're irrational and let them go. People with OCD get stuck in a thought loop—known as rumination. 'How do I know for sure I didn't do something terrible or dangerous or that I won't do it soon?' " Grayson says. "These thoughts produce agonizing anxiety."

That's where the compulsions come in. They're intended to counteract the obsessions and calm the distress. Compulsions range from the rational—cleaning to get rid of microbes or checking the stove to make sure it's off—to the magical. Such magical compulsions can include things like:

• Counting while performing a task to end on a "good" number
• Repeating routine activities, like going in and out of doors
• Repetitive body movements, like tapping or blinking.

It isn't always clear why people develop their unique compulsions or why those particular actions supply relief.

You might suspect you're "a little OCD" if you like to have your pencils arranged just so or if you triple-check your purse for your passport before you board an international flight. But having an obsessive trait or engaging in compulsive behavior doesn't mean you have a personality disorder.

"Obsessions and compulsions in OCD cause real impairment," explains Jeff Szymanski, PhD, executive director of the International OCD Foundation in Boston. For instance, a fear of contamination may drive someone to spend hours cleaning their office every day. "If you have OCD, you don't like the compulsions or want to do them. You have to do them [in order to] relieve your distress," adds Szymanski.

Elizabeth McIngvale, PhD, LCSW, director of the McLean OCD Institute in Houston, who has struggled with OCD herself, explains it this way: "You know the compulsions are irrational, and the relief you'll get is only short-term—maybe 5 or 10 minutes, or an hour—but the urge to do them and the anxiety they're coupled with is so intense you don't feel like you have a choice. When that's the only coping mechanism you have, you use it."

Because compulsions offer temporary relief, they reinforce and strengthen OCD. As a result, when left untreated, the disorder usually gets worse.

Neurological Differences of OCD

Just as your genes can make you vulnerable to OCD, so can your brain structure. "A complex brain circuit, which pays attention and responds to danger signals and involves high-level thinking, emotional processing, and behavior, is hyperactive in people with OCD," says Szymanski. "They're constantly trying to seek certainty—to be sure they washed the germs off their hands or that their spouse is still alive." But of course, it's impossible to be 100% certain of anything.

One thorough handwashing is enough to satisfy most of us. People with OCD are bombarded by niggling doubts. "What if all the germs aren't gone?"

That's not the only neurological difference found in OCD sufferers. While the fear-scanning circuit of the brain is hyper-vigilant, the regions that provide a sense of satisfaction after a task is finished are tamped down.

As a result, people with OCD don't experience a sense of completion when they wash their hands or check to make sure the stove is off, so they feel the need to keep repeating their compulsions again and again. "Some people take 10-hour showers or can't leave the house, while others appear to be high-functioning but spend hours a day battling intrusive thoughts or images," says Szymanski.

Using ERP Therapy

The first step to overcoming OCD is finding a specialist who knows how to treat it. "Fifty percent of medical professionals and one-third of mental health professionals misdiagnose OCD as depression or anxiety or bipolar disorder," says Szymanski. Most aren't trained to treat it, either.

The most effective treatment for the disorder is exposure and response prevention therapy (ERP). ERP is a specific type of cognitive behavior therapy that requires a fair amount of effort on the part of both the therapist and the patient. You can search for therapists via the International OCD Foundation's directory, but be sure to ask your prospective counselor if they have ERP training, says Grayson.

In ERP, a therapist helps you expose yourself to the situations, thoughts, or images that make you anxious—without performing your usual compulsions afterward. If you're worried about germs, for example, the therapist might go with you to the animal shelter, where you can pet a dog and then resist the impulse to sanitize your hands. If your obsession is a fear that your spouse will die, you consciously have that thought over and over during a therapy session, but you don't act on the urge to call and check on them.

"Compulsions tell your brain that your fear is real. When you stop performing them, and nothing bad happens, you begin to break the link so you can see your fears more realistically," Szymanski explains. It's not easy, but over time, ERP actually trains your brain to tolerate uncertainty.

The treatment is effective for about two-thirds of people. Most sufferers experience a significant reduction in their symptoms after 12 to 16 sessions. But it takes steady effort. Szymanski compares ERP to seeing a personal trainer. "If you go once a week and don't do any exercise till the next session, you're not going to see much improvement in your fitness," he says. "But if you work out on your own between sessions, you'll get stronger and lose weight fairly quickly."

Some people also benefit from pairing ERP with selective serotonin reuptake inhibitors (SSRIs), a class of medication that is often prescribed for depression and anxiety. "The drugs seem to change the trigger point for uncertainty by making serotonin more available in the spaces in the brain where nerve impulses are transmitted," says Grayson.

While treatment doesn't cure OCD, it can help sufferers learn to cope with the disorder, so it has less impact on their lives. "When the pandemic first began, we were concerned that people in treatment for OCD would backslide—and many of them did," says Szymanski. "But in talking with many therapists around the world who treat the disorder, we realized that a significant percentage of patients actually handled the pandemic better than people without OCD because they'd learned to embrace uncertainty. They had developed the skills to face the fear and function normally."