Conditions I Treat
OCD can come in many forms, but they almost all have two things in common: unwanted, intrusive, "bad" thoughts, and rituals or compulsions. Exposure therapy involves learning what to do and what not to do when the thoughts come, and also how to learn to resist giving into the compulsions. Although exposure therapy is not fun, it is often very effective, even when the OCD is severe.
The two main symptoms of OCD are unwanted, intrusive, “bad” thoughts, and rituals or compulsions. Examples of intrusive, obsessive thoughts include:
“What if I left the stove on?”
“What if I get some horrible disease from touching that?”
“Am I a pedophile?”
“Am I gay?”
“Am I in the right relationship?”
“Did I just hit someone with my car?”
“What if I stab my husband with this knife?”
“What if I become suicidal?”
“Did I lock the front door?”
“What if I hurt my child?”
“I can’t stand this feeling if I don’t do this ritual”
“This bad feeling will never go away”
Compulsions are things that people with OCD do to try to cope with the discomfort that comes with the obsessive thoughts, and they can be physical (such as handwashing) or mental (such as counting or trying to “figure out” if something bad has happened). Examples of compulsions include:
Excessive handwashing and/or cleaning.
Excessive checking (e.g., doors, stove, lights, locks, places, things)
Repeating rituals (e.g., doing the same movement over and over until the feeling is “just right.”
Spending a significant amount of time mentally trying to “figure out” whether or not the bad thing will or has happened, or trying to get to a “perfect,” “just right” state.
Prayer rituals (where the goal is to reduce anxiety, not to practice your faith).
Re-reading and/or re-writing rituals (e.g., trying to make an essay “perfect”).
Ordering and/or straightening rituals.
Both the obsessive, unwanted thoughts and the compulsions or rituals can be severely debilitating. Everyone has “bad” thoughts, but people with OCD are stuck with having a lot more of them, and are much more bothered by them than people without OCD.
The most effective treatment available for OCD is called Exposure Therapy with Response Prevention (or ERP for short). Exposure therapy is a type of Cognitive-Behavioral Therapy (CBT) that focuses on helping individuals face their fears while also resisting the urges to ritualize. With time and practice, ERP helps by weakening the OCD.
Usually by the end of treatment, the intrusive thoughts have reduced in frequency, and the anxiety associated with them is either gone or reduced significantly. Although no one can make intrusive thoughts disappear forever, ERP will most likely make them very manageable. Additionally, the urge to ritualize weakens to the point that it becomes relatively easy to resist the urge to give in to them, which then further weakens OCD. Exposure therapy works!
Social Anxiety Disorder
Social anxiety can result in school refusal for kids and teens, or significant impairment in work or relationships with adults. Social anxiety is more than just being shy; it is a disorder that makes people worry that others are judging their every move. It makes people feel that they need to be perfect, and it often results in a lot of avoidance of social situations.
Fear of being negatively judged by others is one of the core features of most people with Social Anxiety Disorder. The fear may be that someone will think of them as “weird,” or “stupid,” or “weak.” The fear can be so intense that even making eye contact with someone can be challenging, or it can just be an issue when it comes to public speaking. The main response to this anxiety tends to be either avoidance of social situations, and/or attempts to be “perfect” when around others. For example, this may mean focusing on one’s appearance being perfect, or people-pleasing to avoid conflict. For children, it can make school a very anxiety-provoking place, especially for tweens and teens, for whom fear of not fitting in is already probably a concern. Social anxiety is the main reason for the children I treat who refuse to go to school, and it also is often behind a disorder called Selective Mutism.
Fortunately, CBT is very effective with Social Anxiety. Treatment involves both Cognitive Therapy and Exposure Therapy. In Cognitive Therapy, I teach clients how to recognize and then challenge the irrational thoughts. Next, clients learn how to take these new ways of thinking out to the “real” world, to see if their worst fears come true (they almost never do), and prove to themselves that they can handle whatever does happen, even if it’s something difficult, like being rejected or made fun of. Clients learn how to stop avoiding the situations that make them anxious, and learn to be o.k. with making mistakes/not being perfect, so that they can ultimately be less anxious and more relaxed in social situations.
Panic Disorder and
Panic Disorder involves having repeat panic attacks, and/or developing a phobia of having a panic attack. Agoraphobia is a fear of having a "trapped" feeling, and not being able to escape. They often go together, and can keep people from doing many everyday activities, such as driving, standing in lines, going to the mall, or going to a movie theater.
In order to get a diagnosis of Panic Disorder, a person has to have at least 2 unexpected, “out of the blue” panic attacks, and has to have developed a fear of having another panic attack. Panic attacks are sudden, intense bursts of anxiety that peak in about 5-10 minutes, then subside. Common physical symptoms in a full-blown panic attack can include heart racing, dizziness, light-headedness, chest pain or pressure, tingling sensation, shortness of breath, and several other symptoms. It is the “fight or flight” system going off at the wrong time. Panic attacks are “false alarms” that cue people to think that something horrible is going to happen, such as a heart attack, going crazy, or losing control.
Agoraphobia results in avoidance of situations that make people feel that they can’t escape, such as standing in line, being in crowds, elevators, movie theaters (especially sitting in the middle), classrooms, buses, etc. The fear may be that the person will faint or vomit or lose control in some other way. Often, the worry is that the feeling will be something that they just can’t handle. Agoraphobia and Panic Disorder often go together, but not always.
Exposure Therapy for Panic Disorder and/or Agoraphobia involves education about the nature of panic, and then I often start with doing a type of Exposure Therapy called Interoceptive Exposure Therapy. Interoceptives are exposures designed to purposefully mimic the physical symptoms of panic attacks. The client practices doing them over and over, until they are no longer triggering. Next, we move to doing In Vivo Exposures, which are exposures to the triggering situations (such as being in crowds). The combination of these two types of Exposure Therapy works especially well for Panic Disorder and Agoraphobia.
Generalized Anxiety Disorder
If you worry excessively about every little thing, and it's getting in the way of sleep or other areas of functioning, you may have GAD. A set of skills called Worry Management Skills can make a big difference in how you or your loved one copes with the general stressors of everyday life.
Worrying about everyday things is the hallmark of Generalized Anxiety Disorder (GAD). The common themes for worrying include money, health, crime, relationships, etc. Symptoms that go with GAD can include irritability, insomnia, muscle tension and fatigue. GAD is one of the most common types of anxiety disorders, and many people struggle with letting go of their worries. Typically, people worry about something that may or may not happen in the future. Here are some examples of these worries:
“Will I be late to my appointment?”
“Will I get a bad grade on this test?”
“What if the bill is more than I think it’s going to be?”
“What if my child gets in an accident on the bus ride to school?”
“What if my car doesn’t start in the morning?”
“What if I can’t sleep again tonight?”
“Will my parents get divorced?”
“What if my mom gets sick?”
“What if someone breaks into our garage and steals my car?”
Worrying takes a lot of mental energy, and it really doesn’t do anything for us. It doesn’t help prevent the bad thing from happening, and it doesn’t make us better prepared for it if it does. All worry does is keep us from being relatively at ease with life’s uncertainties, versus learning how to manage the uncertainty about the future in a way that doesn’t make us feel overly stressed. In therapy, clients with GAD are taught Worry Management Skills, which help people to reduce their worry, make decisions about the things that are under our control, and learn to let go of the things that aren’t in our control. By practicing these skills every day, clients with GAD learn to worry less and enjoy life more.
When the main focus of worry is on one’s health, the problem may be Illness Anxiety, formerly known as hypochondriasis. The worry is very specific, and is about the possibility of having or getting a serious illness or disease. Sometimes it takes the form of always worrying about one specific disease (e.g., do I have cancer?), and other times it takes the form of worrying that a physical symptom is a sign of any number of different diseases (e.g., stroke, heart attack, HIV, etc.), and can be triggered by a particular illness being in the news recently (e.g., the Zika virus).
People with Illness Anxiety Disorder will tend to either make frequent calls and visits to their physician, or will avoid seeking medical attention. Compulsive Internet research on websites such as WebMd and Mayo Clinic can also become a time-consuming and unhelpful way to try to reassure oneself that you don’t have whichever particular disease you’re worrying about at the time. Exposure therapy is also the treatment of choice for Illness Anxiety Disorder.
Sometimes people have fears about a single thing, which is called a Simple Phobia. Examples include fears of insects or snakes, heights, vomiting, and storms. When the phobia starts getting in the way of everyday functioning, it's time to seek help.
Exposure therapy has been used since the 1960’s to treat phobias. Specific phobias are irrational fears and avoidance of a single thing or situation, such as fear of insects/snakes, storms, enclosed spaces, vomiting, heights, etc. Many people have mild fears of certain things and/or situations, but most people don’t seek help for them because they can generally live their lives without having to treat their phobia. In other words, just because you’re afraid of spiders doesn’t mean you need treatment. However, when the phobia begins to interfere with your ability to do the things you want to do, then it’s time to seek help. Exposure therapy works relatively quickly with specific phobias, and is highly effective if done as prescribed.
Fears associated with Hoarding Disorder include the fear of not having something one “needs” or losing a precious memory. Two types of symptoms are generally typical of clients with Hoarding Disorder. The first is the compulsion to buy and save things that most people don’t buy and/or save. Examples of these things include saving junk mail, receipts for small purchases, buying 3 or 4 of the exact same clothing item, not being able to resist a “sale” or “good deal,” etc. There can be a buyer’s “high” that quickly goes away when the person gets home. Often, purchases aren’t ever used or looked at again, and instead are placed somewhere in the house on a pile of other items that have been bought and not used.
The second typical symptom is the inability to discard items, even if they haven’t been looked at or used for years, and are taking up much-needed space in the home. The distress levels are very high when the idea of discarding arises, making it nearly impossible to follow through with the initial goal of clearing out the house.
Sometimes, Hoarding Disorder is associated with Attention Deficit Hyperactivity Disorder (ADHD), and part of the problem is a lack of the skill of knowing how to organize things. But even with good organizational skills in place, Hoarding Disorder can become a serious issue. Unlike most of the Anxiety-Related Disorders, Hoarding Disorder typically takes 1-2 years to treat. This is important information for loved ones who tend to have unrealistic expectations for the level of difficulty involved in 1) stopping the buying/saving, and, especially, 2) discarding all of the accumulated items that are cluttering up the home.
Therefore, involving family members early on in treatment is important whenever possible, so they can be educated about the treatment plan, and be supportive and helpful. Hoarding Disorder is treatable with a willing client, but the treatment does take more time on average than most anxiety disorders.
Body Dysmorphic Disorder
BDD is characterized by a strong belief that some aspect of one’s appearance is seriously defective, or “ugly,” and no amount of reassurance from others will alter this negative belief.
Common areas of concern with BDD include one’s hair, skin, and nose, but BDD can target any aspect of one’s appearance. Some typical negative beliefs include thinking that one’s hair is too “shiny,” or that one’s nose is “hideous,” or that one’s complexion and/or acne or “gross.”
Often, other people don’t see the person the way they see themselves. In other words, loved ones often don’t see what the person with BDD is even referring to. In fact, people with BDD tend to be considered more attractive (based on cultural norms) than people without BDD, which makes it even more difficult for loved ones to be sympathetic and understanding of the person’s distress. This inability to elicit empathy from loved ones, combined with the intensity of the belief, all contribute to a high rate of suicidal thinking in this population, making it even more important to seek professional help.
CBT and Exposure Therapy interventions help people to learn how to stop avoiding situations that trigger them, and start living the life they want and deserve, versus letting these strong negative beliefs interfere with their functioning. Exposure therapy also helps individuals to reduce any rituals that may have developed, such as repeatedly checking their appearance in the mirror/reflective surfaces.
An intense fear of being separated from one’s caregivers is the hallmark of Separation Anxiety, and usually starts in childhood. Left untreated, it can persist in to young adulthood.
The fear is that one’s parents or other loved ones will die if you are not reassured that they are safe. Separation from parents/loved ones can then trigger intense fear until the individual gets that reassurance, either by talking to them on the phone, texting them, or seeing them again in person.
Sometimes children and teens will have difficulty sleeping in their own bed, because the separation of being in a different bedroom from their parents causing such high levels of anxiety. Other times, it affects the ability to be at school during the day, or being able to stay alone at home as a teenager when parents are out of town.
Exposure therapy for Separation Anxiety involves helping clients learn to tolerate the normal uncertainty that comes from temporary separation during the day or week, and learning how to resist the urges to get reassurance that their loved ones are o.k.
Post-Traumatic Stress Disorder
PTSD can develop in individuals who have experienced significant trauma, e.g., a bad car accident, being a victim of a violent crime, or surviving a tornado. The fear and anxiety from the traumatic event makes some people start to avoid aspects of the trauma, such as talking about it, remembering it, or being around reminders of it. Although these responses are normal at first following a traumatic event, if the avoidance persists, it can develop into PTSD. Exposure therapy for PTSD involves gradually reducing this avoidance, so that individuals can function normally again, with significantly less anxiety.