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Help for OCDers Online
Having recently worked with several creative and dynamic people living with Obsessive Compulsive Disorder (OCD), I was lucky enough to glean some ideas from them about how utilizing online resources has helped them to ease the mental and emotional burdens of OCD. Here are some of the key ideas and recommendations that they offered.
People with anxiety can find help in “the cloud” in a variety of ways. One of these is finding a sense of connection and community through sharing experiences with other OCDers on social networking sites like Facebook and Twitter. Sometimes, these online connections can turn into in person connections as people share updates about regional OCD treatment resources and other ideas such as local support groups and events. I should hasten to add that it is always important to be careful and confirm that the social media sites and other websites are legitimate, credible sources of information rather than platforms for un-empirically supported fringe treatment ideas or questionable, unaffiliated meet-ups. Of course, without ever having to have contact with anyone, reading OCD-related blogs can often provide someone a sense of community.
And speaking of blogs, self-expression in blogs can be a way that OCDers share their experiences and find meaning in their anxiety.
Other “cloud computing” resources include organizational help with online calenders like Google calendar, help with personal finances with personal finance website tools and using online bill pay and direct withdrawal. The idea with using cloud computing for daily organizing tasks is to “set it and forget it,” or put an organized system in place, then let it run without excessive anxiety or checking on it.
In other words, using online resources is a way of helping take back control from the OCD, turning away from fruitless striving for perfection and being willing to embrace the messy but effective way that these 21st Century tools can streamline life, leaving a lot more room for what matters.
Reflections on the New Agoraphobia Diagnosis
What constitutes a “mental disorder” and what doesn’t, is officially determined by an 
official clinical manual called the Diagnostic and Statistical Manual, or the DSM. Mental health clinicians have been using the DSM-IV since around 2000. But now, at long last, the next addition of the DSM is set to be published in 2013. Of particular relevance to psychologists and others who treat people struggling with panic attacks, the DSM-V will reportedly feature major changes to the diagnostic criteria for panic disorder and agoraphobia. Specifically, Panic Disorder and Agoraphobia will be separated into two distinct mental health disorders.
The diagnostic criteria for Panic Disorder will largely stay the same, except that all mention of Agoraphobia will be excised from it. As a separate codable diagnosis, the first two proposed criteria for Agoraphobia will be the following:
Criterion A: Extreme fear or anxiety concerning two or more following agoraphobic situations: 1) being outside the home alone, 2) public transportation, such as airplanes, buses, subways, etc., 3) open spaces, including large parking lots or markets, 4) being in stores, theaters, or cinemas, or 5) standing in a line with other people or being in a crowd of people.
Criterion B: The person has become afraid of and may additionally be avoiding these situations because they feel it would be difficult to escape or help would not be available if they were to experience a panic attack or pass out.
You can read all the proposed criteria here. It’s difficult to know how the set changes in the DSM-V will affect treatment and insurance compensation over the long term, but it does seem to me to be the case with various agoraphobic people I have worked with that their phobic avoidance of venturing outside or into populated space sometimes seems to evolve in a way that they have certain focal fears–such as heart stopping or spontaneous suffocation–that are related but not the exact same thing as having a panic attack. In other words, people struggling with agoraphobia do not always necessarily say that they are afraid of having a panic attack, per se, but rather, after some exploration, they voice whatever their focal fear is, along with the imagined shame and embarrassment of having it happen in public.
So, for the time being I will remain provisionally supportive of this change to the DSM-V, which may result in a more accurate characterization of the distinct struggles faced by those suffering from Agoraphobia.
Posted in Help for Anxiety, Panic Disorder
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Anxiety about Retirement: A New Perspective
A new poll conducted in October by the Associated Press and LifeGoesStrong.com found that 73% of Baby Boomers now plan to work past retirement, and 53% said they don’t feel comfortable that they’ll ever be able to afford a comfortable retirement. These are big numbers, and speak to a substantial increase in anxiety for Americans at or nearing retirement age.
Of course, most people experience uncertainty about the future all the time. A degree of anxious uncertainty about the future is a normal, if trying, part of the human experience. But some people are particularly debilitated in their thinking by uncertainty because they find uncertainty about the future terrifying. Psychologists call this an intolerance of uncertainty, and it is thought to underlie many anxiety disorders, including Generalized Anxiety Disorder (chronic worry) and obsessive compulsive disorder. Another anxiety-related diagnosis that is not discussed as often is Adjustment Disorder with Anxiety. People who find they are consumed with depression or anxiety and unable to function after a specific precipitating event or change has taken place can be diagnosed with this. When I think about the anxiety about retirement that many Boomers are facing today, I sometimes look at it as a generational adjustment disorder with anxiety, with the precipitating event being the 2008 financial crash in which so many lost much of their savings and financial security.
One way that adjustment disorders can be treated is to focus on the steps of a transition, which include 1) an ending, 2) an uncertain, limbo period and 3) a beginning. It can be reassuring to re-frame an upsetting change in these terms. So for Boomers the ending has already happened: that was the 2008 crash that ended their previous feeling of security. Now it appears they are in the limbo period, which is by its nature an anxious time. At this agonizing juncture, re-focusing on how change brings renewal and new opportunities for growth can help people to grieve what’s been lost and experience a kind of new beginning, which typically has the effect of neutralizing the worst of the anxiety.
Posted in Help for Anxiety, Worry
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Anxiety Disorders on the Rise
The Anxiety Disorders Association of America (ADAA) estimates that anxiety rates have continued to rise steadily over the decades. Today, the ADAA estimates that more than 40 million people suffer from anxiety disorders in this country, based on prescription drug sales. And younger generations seem to be most affected. But if anxiety disorders really are on the rise, the question is…why?
Even with major events like 9/11 causing widespread fears of terrorist attacks, and the economic collapse of 2008 causing deep financial insecurity, how could current times be more anxiety-producing than the Great Depression, or World War II?
One recent idea is that modern popular culture and the media have essentially inflated expectations of how much average people can achieve and how much pure happiness life offers. Living in the Great Depression was miserable, in other words, but the hardscrabble life of those times was in line with popular expectations, and therefore did not produce as much anxiety. This idea is related to the concept that the younger generations (“Gen X and Y”) were raised by their boomer parents to hold starkly unrealistic expectations of their own competency and the degree of success and acclaim they are likely to achieve in life. These generations are, in a sense, sufferers of a cultural disease of narcissism. This idea is most fully explored in San Diego State University psychology professor Jean M. Twenge’s 2009 book The Narcissism Epidemic: Living in the Age of Entitlement, as well as her 2006 book Generation Me: Why Today’s Young Americans Are More Confident, Assertive, Entitled—And More Miserable Than Ever Before.
The question of why anxiety disorders are on the rise–especially for the younger generations–is a complex one that is likely answered by many factors. It does make intuitive sense, though, that expectations of achievement in life could play a pivotal role, and that those whose expectations have been unrealistically inflated have been set up to fall into an anxious downward spiral.
Posted in Help for Anxiety, Worry
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Chronic Worry in the Past and Present
People with Generalized Anxiety Disorder (GAD) do a lot of one thing: worrying. One of the most common and widely-accepted ideas about how chronic worrying works is that chronic worriers have a deep and pervasive difficulty tolerating uncertainty. I like the way that the psychologist Dr. David Carbonell talks about GAD on his useful website anxietycoach.com. He says that GAD involves four related processes: 1) arguing with your thoughts, 2) fearing your thought–worrying about the fact that you’re worrying so much, 3) getting caught up in constant “What if’s” and 4) asking How can I be sure?–that the bad thought (no matter how unlikely it is in the first place) will never become a reality.
Effective cognitive behavioral treatment for GAD is very focused on the present. The aim is to help chronic worriers beat worry by changing your response to worry thoughts, i.e. to accept their presence as unhelpful white noise, rather than trying to change, dispute or dispel the thoughts themselves. After all, doing the latter would wind you back up in the same predicament of arguing with thoughts that got a person stuck in chronic worry in the first place.
Outside of treatment, which is best when it’s present-oriented, it can be interesting and useful to seek to understand how and why certain people become susceptible to chronic worrying more than others. On this question, some interesting ideas have been put forward by Dr. Robert Leahy, director of the American Institute for Cognitive Therapy in New York City. As you can read more about here, Dr. Leahy says that in addition to a genetic or inherited component, messages that one receives growing up may also play a role. For example, people who were over or under-protected by parents can develop global ideas that (for under or inconsistently protected people) the world is an inherently dangerous, risky place or (for overprotected people) that they themselves are particularly fragile and ill-equipped to handle uncertain situations. Finally, and interestingly, Dr. Leahy states that “reverse parenting,” or cases in which the child was forced to play a caretaker role to an under-functioning parent, may also predispose someone to chronic worry. Dr. Robert L. Leahy is also the author of The Worry Cure: 7 Steps to Stop Worry From Stopping You.
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Angel and Jason: pushed to the brink by Panic
Over the last ten years, I have had the opportunity to work with people all along the economic spectrum. For some years I was a counselor at a residential treatment center–some would call it a halfway house–for chronically mentally ill adults located in Portland’s hard-scrabble Old Town. Working there, I came in contact with many people in the grip of drug and alcohol addiction. But what I didn’t understand back then was how acute anxiety conditions can be a major driver of drug and alcohol abuse.
That was the case for one of the residents of the halfway house named Angel. She identified herself and told her story in this 2008 Portland Tribune article. In the article, Angel tells reporter Chris Lydgate that shortly after she graduated from Lincoln High School “She began suffering from panic attacks, which she doused with vodka.” After a decade of being relatively functional despite increasing alcoholism, her ongoing panic condition eventually led to a harrowing downward spiral into addiction to street drugs and homelessness. She tells the reporter, “’I should have learned my lesson,’ she says, tears rolling down her cheek, her mouth clamped into a circumflex. ‘I get blindsided by the panic, and I just freak out.’”
I knew Angel, and her struggles reminded me powerfully of a prison inmate, “Jason,” who I worked with more recently. For years, Jason had also been “dousing” his acute panic condition with marijuana and heroin use. Sitting in the room with him, he at first appeared mellow and bored, but I soon realized that was a stoic front he had to maintain in prison, and that in fact he was on a constant hair-trigger for approaching sensations of panic. When he felt panic sensations, Jason would return to his cell as fast as he could to have the panic attack in there. He felt profoundly trapped: he desperately wanted to get off of heroin and have a career and a relationship with his son, but he felt hopeless, knowing he would almost certainly return to heroin after he released because he knew of no other way to live with the all-consuming panic. In the end, Jason’s anger and despair drove him to impulsively give up on therapy. Drugs were the only thing he knew that allowed him at least a faded life with the panic–they were his lifeline.
In addition to the intensive drug and alcohol treatment they both needed, it makes me sad to think of what a transformative effect exposure-based CBT would have had for Angel and Jason’s lives. They both lived in numbed misery. Panic denied them the pride and fulfillment of meaningful careers or the joy of taking care of their children. If only they had had the chance to engage in a course of exposure-based panic treatment, it could really have turned their lives around. I can only reflect that they’re both still out there, so far as I know. Maybe someday that chance will come.
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The Magic Radio
I often find that metaphors are a very rich way to capture concepts that are difficult to convey by simply describing them. Over the years I have been treating anxiety disorders I have borrowed, adapted and occasionally even developed on my own a number of metaphors that my clients have said were useful. I thought I’d share one of the more popular ones with you on this blog. I’ll share more with you in future blogs.
If this metaphor is one that someone else has developed and I’m borrowing it from you then I apologize in advance, but I believe this is one that has evolved in my work with numerous clients over the past several years. I treat a lot of clients with Obsessive Compulsive Disorder (OCD) and many times I have been asked what to do with obsessive thoughts that simply won’t stop. Despite numerous attempts to stop them, the thoughts just keep coming and coming. Sort of like the Energizer Bunny who just keeps going and going. What is one to do? Though the question is quite simple the answer is not. Part of the answer is acceptance (more about this concept in future blog posts). If you can’t stop it then what choice do you have? Trouble is that we don’t want to accept (there’s that word again) that we can’t control these frustrating, bothersome and usually scary repetitive thoughts. It is in the very nature of OCD that we are going to have repetitive thoughts and so acceptance is the only reasonable option (at least in the short run).
Let’s say you just purchased a brand new big screen TV and just finally got it set up in your family room. You have also just received in the mail a new DVD from Netflix that you have been eager to watch for a long time. So here you are at last with your new TV, DVD and you just made a big bowl of popcorn and are settling down to finally watch your movie. Unfortunately in the same room as the TV is an old radio playing and there is no way to turn the radio off. Let’s call it for this metaphor a magic radio because no matter how much you try that darn radio won’t turn off. In fact, it almost seems as if the more you try to turn it off the louder it gets! What are you to do? If you focus on the radio then obviously you are going to miss watching your movie. So the only choice that makes sense is to tolerate the radio as best you can and focus on enjoying your movie. Will that mean you will probably enjoy the movie a bit less because of the radio? Probably, but again what choice do you have? Fussing over the radio doesn’t change anything, because the radio will keep playing no matter what you do.
An even more insidious and frustrating aspect of the radio is that what it is broadcasting sounds as if it might be important so how can you possibly ignore it? Perhaps you should wash your hands again to be sure every last germ has been washed away. Perhaps you should check that light switch one more time to be sure the lights are off. How can you ignore these threats? Most people with OCD know that their thoughts are exaggerated and they don’t really need to wash or check again, but they are “seduced” by the radio into listening anyway. The more they “listen” to the radio the less they are watching their movie. I hope you choose to watch you movie and do the best you can to ignore the radio.
Posted in Obsessive Compulsive Disorder
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Body Focused Repetitive Behaviors
Most people have heard of Obsessive Compulsive Disorder (OCD), but many are unaware of what are called “OCD Spectrum Disorders”. One category of “OCD Spectrum Disorders” is called Body Focused Repetitive Behaviors or BFRB’s. The BFRB’s that we see most often at our anxiety clinic are Trichotillomania and Dermatillomania, which most people have never heard of. These two disorders are, respectively, pulling out ones hair and picking ones skin. BFRB’s can also include other behaviors such as nail biting or biting the skin inside of one’s mouth, though Trichotillomania and Dermatillomania are by far the most common BFRB’s that we see. The hair pulling can be from any part of the body, but is most often from the head, eyelashes or eyebrows and occasionally from the legs or pubic area. Skin picking can, likewise, be at any location on the body but face, scalp, legs and arms are most common. These are called “OCD Spectrum Disorders” because they co-occur frequently with OCD.
The hair pulling/skin picking can range from occasionally pulling out a stray hair or two to pulling out entire eyebrows, eyelashes or large patches of hair on one’s head. Skin picking can have similar variations ranging from removing a few “bumps” on the skin to creating large sores/scabs from all the picking. Our clients are universally extremely frustrated by their inability to stop these behaviors that appear so self-destructive.
BFRB’s can either be focused (you are aware of what you’re doing) or unfocused (you don’t realize you’re pulling until you happen to look down and see the pile of hair on the floor next to you). Treatment often begins by keeping a diary of pulling/picking episodes over the course of several weeks to become more and more aware of when and–with some luck–why you pull/pick. The diary also has the effect of making you more aware – so that what was “unfocused” behavior becomes more and more “focused”. This is a necessary step because if you are unaware of what you’re doing it is virtually impossible to stop. Becoming aware is, unfortunately, often only the first step. Some people will find that the diary helps them stop their pulling/picking, but most people will find it is a necessary but not sufficient condition for change.
Besides raising awareness, the diary helps us pinpoint where, when, how and even sometimes why we pull/pick. If we know where and when we pull/pick then when we go “there” at that “time” we can be especially careful to not start the BFRB in the first place. Of course this is much easier said than done, but it is a start. Knowing “how” we pull/pick can also be very useful. If we know, for example, we usually use the thumb and first finger on our right hand to pull out the hair, then we can cover those fingers (band aids or gloves) and thus reduce the probability we will pull/pick. In fact, using “barriers” is one of the more effective and easily implemented treatment methods. The “why” we pull/pick may be an attempt to regulate our emotions. If we are upset it may be an attempt to calm ourselves down and vice versa, if we are bored it may be an attempt to rev ourselves up a bit.
Few people have ever heard of BFRB’s and know that these disorder even exist, and fewer still realize that there are treatment methods for these disorders. An excellent source of information and resources for BFRB’s is the Trichotillomania Learning Center (www.trich.org) in Santa Cruz, California. It is full of very useful information. There is even a therapist locator service to help you find a therapist in your area who is qualified to treat BFRB’s.
Worry: the Agony of Not Knowing
We all worry and feel stressed at times; it’s part of the human condition.But most people 
know someone whose entire thinking style seems to be riddled with worry almost all of the time, like an instrument that can only play songs in one key. These chronic worriers may have what psychologists call Generalized Anxiety Disorder (GAD). GAD is diagnosed when a person worries persistently, excessively and unrealistically about a whole range of everyday issues for 6 months or more. If the condition is of mild severity, a person may still be able to work and function socially, but when it is severe, a person’s worry consumes and incapacitates them. People with acute GAD can even worry themselves into panic attacks. In U.S. society, women are twice as likely as men to be afflicted with GAD.
Earlier, I used the term “thinking style.” This is meant to convey that chronic worrying is often an entrenched pattern of thinking, but that the pattern or style–like styles of driving, dressing or TV watching–does not have to be an incurable lifelong fait accompli. It takes self-awareness and perseverance, but people change their styles of thinking and relating to others every day. Cognitive Behavior Therapy treatments for GAD are based on a combination of cognitive restructuring and exposure to fear of consequences (that, happily, usually don’t come to pass).
With a therapist’s help, chronic worriers can become more aware of how they are thinking about everyday issues. Usually, they find that they are making cognitive errors such as all-or-nothing thinking, jumping to conclusions, catastrophizing, and overestimating the likelihood of something dangerous happening*. By repeated practice, they can learn to catch themselves making these errors and gradually sift them out of their thinking.
Along with cognitive restructuring work, exposure treatments for GAD involve purposefully holding back from seeking reassurance that a feared consequence might happen. Enduring the discomfort of not knowing what is going on with a loved one, a job application, a health condition. Because, at it’s most elemental level, GAD is a disorder of intolerance of uncertainty. An afflicted person just can’t stand the agony of not knowing what is happening or what will happen, and lives in constant mental and physical agitation as a result.
To be able to accept and even to embrace life’s endless mysteries and uncertainties is part of the definition of mental health. It is the vision of recovery that every loved one and every therapist holds for the chronic worriers we care about and want to see healed.
* These terms were developed by Dr. David Burns in his groundbreaking cognitive therapy book Feeling Good.
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