Obsessive Compulsive and Related Disorders in the DSM 5 TR | Symptoms and Diagnosis

Hey there everybody, and welcome to today's presentation on obsessive, compulsive and related disorders in the DSM 5TR. I'm your host, Dr. Donnellice Snipes. Today we're going to review the disorders in the obsessive, compulsive and related disorders category, explore the diagnostic criteria for OCD and hoarding disorders specifically and identify associated features and alternative or differential diagnoses. The disorders in this category include of course, obsessive Compulsive disorder. It also includes body dysmorphic disorder. I've done other videos on body dysmorphic disorder and there is so much there that we're not going to talk about that one today. I'm actually going to cover it when I do eating disorders in the upcoming video hoarding disorder we're going to talk about today. Trichotillomania and excoriation disorders are also in here. So that is hair pulling or skin picking, substance induced obsessive compulsive disorder or other specified obsessive compulsive and related disorder. And the DSM 5TR includes with this nail biting, lip biting, cheek chewing, obsessional jealousy and olfactory reference disorder. Olfactory reference disorder is when you believe that you are emitting an odor that everybody else can smell, even though they can't really smell it. You believe you are admitting it, emitting it. And the person who has olfactory reference disorder may go to great loss lengths to try to mask that smell that they believe that they're emitting. So let's talk about some prevalence here. The prevalence of obsessive Compulsive disorder in the DSM 5TR is identified at 1.2%. And when you look at the research up until 2019, 2020, that was pretty stable and it seems to be pretty stable across cultures. However, when the pandemic hit, post pandemic, we have seen an increase in obsessive compulsive disorder symptoms in the general population, ranging between 60.3 and 62.4% of people in the general population. This is not just health care workers. This is not just people who have comorbid mental health issues. This is in the general population. Just let that sink in for a second. It doesn't necessarily mean they all rose to the level, if you will, of meeting the diagnostic criteria for obsessive compulsive disorder or that they continue to meet that. However, living through the pandemic, I think we can safely say that the majority of people who develop symptoms probably did, at least during that period, meet criteria. Now, whether you Want to diagnose it as OCD or illness anxiety disorder. We're going to talk about that later, but I think that is very interesting. However, you know I said the prevalence of OCD symptoms skyrocketed. Yes, they did. But it was only related to contamination and illness related symptoms and not other types of obsessions and compulsions such as ordering or safety or things like that. So that was kind of interesting. What the take home is for that, for you who are in private practice or even working in clinic, is that you're probably going to see a lot more people with OCD symptoms. And my guess is, and this is just from clinical experience, not from the DSM5TR, but my guess is as we start to approach the next flu season, we may see an uptick in OCD or illness anxiety related behaviors that we need to pay attention to because it can be extremely disruptive to a person's life. We'll go into that when we get down to treatment. Excoriation and trichotillomania represent about 2.5% of people. So two to three people out of every hundred struggle with excoriation or trichotillomania. Now we want to differentiate that from body dysmorphic disorder and there's a whole lot of overlap there. So. And again, we'll talk about that. And hoarding disorder impacts approximately 2.6% of people in the general population. Let's start out by talking about obsessive Compulsive disorder. This is the umbrella diagnosis for this chapter. The person has to have the presence of obsessions, compulsions, or both. So to be diagnosed with obsessive Compulsive Disorder, they don't have to have both. They can have obsessions, compulsions, or both. That is a common misdiagnosis or misconception that people have when they're making diagnoses. Obsessions are defined as recurrent and persistent thoughts, urges or images that are intrusive and cause marked anxiety or distress. That's pretty self explanatory. The person tries to ignore, suppress or neutralize the thoughts, urges or images through behaviors or activities or other thoughts that they engage in. And those are the compulsions. Compulsions are repetitive behaviors or mental acts people do in response to an obsession or according to rigid rules. Okay, so there's another little or there not an and but or they may do it in response to an obsession. So they have the intrusive thought or intrusive image and they start engaging in this compulsive behavior or mental act in order to get that out of their head. However, some people with obsessive compulsive disorder may adopt rigid rules for things that they have to do in order to prevent the onset of obsession sessions, in order to prevent bad things from happening. So the rigid rules, especially in somebody who has long standing obsessive compulsive disorder, may account for people's prevention sort of strategies. They're trying to not have that happen. They're trying to engage in whatever activities or mental acts they need to do in order to not have those intrusive thoughts or images. Compulsions are aimed at preventing or reducing distress or preventing a dreaded event. However, these behaviors or mental acts are not connected in a realistic way with what they're designed to neutralize or prevent. A common example, Some people may fear stepping on cracks because they think it will cause some sort of catastrophe. There's no connection between stepping on cracks in the sidewalk and causing a catastrophe. But that can become a very common obsession in obsessive compulsive disorder. Therefore, the behavior of avoiding stepping on cracks may become very prominent, or the behaviors may be connected to, but clearly excessive. So instead of washing your hands once for 20 seconds or a minute with warm water and soap, the person may wash their hands 20 times and then still not be certain that they've accomplished the task. It's important to note if you're trying to diagnose OCD in young children. They may not be able to explain explain the purpose of these behaviors or mental acts, but they need to do them. And that makes it a little bit more difficult to differentiate from autism spectrum disorders, where there are repetitive behaviors and difficulty with changes in routine. But it becomes apparent when you're taking a much greater longitudinal assessment of what's going on, whether it's obsessive compulsive disorder or autism spectrum disorders. Obviously, in ocd, a lot of the symptoms of autism spectrum disorder are not going to be there. Obsessions or compulsions take more than one hour per day or cause clinically significant distress or impairment in one or more areas of functioning. It is important to recognize that this is another one of those or clauses. It can take one or more hour per day, which is deemed excessive for whatever it is, or it causes clinically significant impairment, or both. But you don't have to have both. The person's behaviors can be very egocentatic and it may not cause them clinically significant distress. It may cause them clinically significant impairment by another person's assessment. So we do want to recognize that. And symptoms are not attributable to the physiological effects of a substance, a medical condition or another mental disorder. Content of obsessions and compulsions can be just about anything. However, some common themes. Contamination from bodily fluids, from germs, from toxins in the environment. The person may engage in behaviors like cleaning or changing what they do, like washing their clothes in order to get particular chemicals out of them, and reassurance seeking from doctors, from other people. Is it clean? Am I clean? Did I do it well enough? Symmetry, straightness, ordering and counting compulsions are also common. Symmetry where, if you're looking at, for example, the fireplace, there has to be symmetry on either side of the mantle, or at the dinner table or wherever the person is, there must be symmetry. And if it's asymmetric, if there's imbalance, maybe there's a big thing on one side of the mantle and nothing on the other side. It may cause them distress. Now, where that distress emanates from, we need to explore what's going to happen if there's no symmetry. Same thing with straightness. And I know there's a lot of people who are particular about pictures, making sure that they're hung level, and if they're not level, it bugs them. But does it rise to the level of causing clinically significant impairment? And. And does straightening things or leveling things take more than an hour a day? For most people, the answer is no. But it may be something that is frustrating to the individual because the unstraightness or the unlevelness of something just bugs them and they can't seem to let it go. Taboo thoughts, and this can be religious thoughts, aggression thoughts, sex thoughts, whatever the thoughts are that the person perceives as bad or taboo. And they may engage in related compulsions to either atone for those thoughts or to make those thoughts stop. Harm. People may have obsessions about harm, about a fire happening, about somebody breaking in, about getting in a car accident, anything that could cause harm to themselves or somebody else, which may result in checking, making sure they turned off the iron or the stove or locked the doors, and reassurance seeking, discarding objects for fear of harming others is another common content of obsessions and compulsions. Some people would believe that if they discard some object that it is somehow materially connected to another person. So if they discard that, it actually physically injures the other person. We're not talking about, if I throw away the vase that somebody gave me, it's going to hurt their feelings. We're talking about if I get rid of this, it's actually going to cause physical harm to this person. Losing control and acting on impulses is another fear. Whether they fear they're going to act on aggressive or sexual impulses or just lose control in the middle of somewhere. And losing control is a common concern in people with agoraphobia, too. So you want to make sure that you differentially diagnose what's going on there. Losing or forgetting something important is another obsession that some people can have. We want to differentiate this from other diagnoses like adhd, in which losing or forgetting something important is very common, and they may not have compensatory strategies to help them avoid doing that. And they may. That may cause them a fair amount of anxiety and incompleteness. Not feeling, feeling like if they get rid of something, that they're losing themselves. And this is obviously more prominent in hoarding disorder. But if they get rid of a photo album or if they get rid of their high school textbooks, or if they get rid of something else, they may fear that it actually takes a part of them with it. Hoarding disorder persistent difficulty parting with possessions regardless of their actual value. A lot of people with hoarding disorder have collected things for a long time, and some of these things may even be old newspapers, and not from significant events, but just over newspapers or flyers that they've gotten or even takeout menus. This difficulty is due to a perceived need to save the items. I need this just in case. And to avoid distress associated with discarding the item. They think they need it and they're afraid that they're going to experience distress if they discard it. And it stresses them out if they get rid of it, because then they start wondering, well, what if I need that again? So there's a lot of anxiety and distress associated with parting with that thing. The difficulty discarding possessions results in cluttered, compromised living areas. Now, this is important. There can be a little bit of clutter, and there can be a lot of clutter and compromised in attics, in basements, in garages, in closets. That's not what we're talking about. When we start talking about hoarding disorder, it must. The degree of the clutter and compromise must spill out into living areas. So maybe completely covering the dining room table. So you've got to move stuff out of the way in order to even sit at the dining room table, or not being able to sit on the sofa because there's so much stuff, you've got to move it to the floor in order to find a place to sit. Sit. That's what we're starting to talk about. If living areas are uncluttered, it's due to the intervention of third parties. For children, this may be their parents. For adults, this may be significant others or cleaning crews that they've hired to come in. However, after the cleaning crew leaves, they start collecting more stuff again. A lot of times the person with hoarding disorder is not going to intentionally hire a cleaning crew because that cleaning crew would separate them from their stuff, which would cause the distress. Hoarding causes clinically significant distress or impairment and is not attributable to another medical or mental health condition according to the DSM 5tr. Now, not as a part of the diagnostic criteria, but in the write up of hoarding disorder, one of the things that we need to notice is that 80 to 90% of cases may have something called excessive acquisition, which means they just get too much stuff. They keep gathering stuff. It's not like they get something like a textbook from high school or college and they keep it and they have difficulty parting with it. They're actually ordering more textbooks, they're ordering more stuff than they actually need. Separation from items or prevention from acquisition of new items may prompt distress. And this is important to recognize. It's not just saying, okay, Sally, you're not going to get collect anything else and then you're going to start separating from things. Both of those things are going to cause Sally distress. So we need to explore what is the meaning of this behavior? What function does this behavior serve? And it's important to recognize that most obsessive, compulsive and related disorders are triggered by or contributed to by experiences of trauma. Therefore, we want to ask ourselves, remember, trauma strips people's sense of safety and empowerment. In what way do the the compulsions. In what way does the hoarding. In what way does the skin picking or hair pulling contribute to that person's sense of control and safety in their environment? Animal hoarding includes accumulation of a large number of animals and failure to provide minimal standards of nutrition, sanitation, and veterinary care. Many people who hoard animals also hoard stuff. We want to look again. What might that behavior mean? Most people who hoard animals, it's not like they're collecting like this would be neat. That would be neat. Most people that I've encountered, and I've been in animal rescue for 25 years, who hoard animals, they're hoarding the rejects, they're hoarding the ones, the homeless animals, they're hoarding the ones that are injured, they're hoarding the ones that Just get dumped. And so we need to look at how does that parallel those animals? How do those animals parallel with that person? They may not be willing to get rid of the animals or adopt them out. How does that, what does that mean to that person? That person says, I'm the only one who can guarantee this animal is going to be loved, even though objectively that may not be what's happening. If that's going on, we need to ask ourselves, you know, in what way is this a recapitulation of this person's childhood? Maybe nobody took care of them, so now they're trying to take care of all of the discarded and the injured and unwanted animals. We want to look for parallels because behavior has meaning in terms of the development and course of obsessive compulsive and related disorders. The mean age at onset of OCD is 19.5 years, and the mean age of onset for hoarding is 15 to 19. So what we're seeing is a mean age of onset age in early to mid adolescence. Well, let's think about what's going on there. This is a time of individuation. This is a time of kind of stress and identity development. This is a time of huge hormone swings. This is a time of a lot of turmoil for a lot of people. How is, how are the biological changes, how are the cognitive changes, how are the socio emotional changes that are happening in that individual? How are they contributing to the development and course of the ocd? Were there triggering events? Were there traumas that happened? Was there superstitious reinforcement? Maybe they were. Taking a bath and something bad happened, so now they won't take a bath, or they've got to do a certain set of rituals before they can take a bath. That's superstitious reinforcement. I did this, and this bad happened. Therefore what I did must have caused it. That's not, you know, we can see that those two things, there's no connection. But, but the person may have made that connection in their head. And it's important to recognize, especially in younger people, that superstitious reinforcement is not uncommon. So we need to, in treatment, eventually help them uncouple their responsibility and their sense of heightened power in different events. Symptom onset for OCD is typically gradual. However, acute onset can also occur during the pandemic. We saw a lot more acute onset where it became very overwhelming very quickly and people started worrying about everything. However, onset may be very gradual where they start worrying about germs and washing their hands, and then, you know, maybe they maybe they washed their hands, but they got sick anyway. So now they worry about germs. And washing their hands once isn't enough. They need to wash them twice or three times. So you can see how this might develop over time. If they engage in a behavior to prevent harm and that behavior fails to adequately do it, they may develop alternate behaviors or intensify that behavior in order to prevent it in the future. Let's talk about trichotillomania and excoriation. So, hair pulling and skin picking, recurrent hair plucking resulting in hair loss. Now, this is important, and as is the clause about causing clinically significant distress. If you're plucking your eyebrows, yes, that may lead to hair loss in areas where you want hair loss. So that's not what we're talking about. We're talking about recurrent hair pulling resulting in permanent hair loss or skin picking resulting in lesions, resulting in sores on the body, unsuccessful attempts to stop. So obviously this isn't something the person wants to be doing. It causes them clinically significant distress. And it's not due to another medical condition, substance use, or a mental disorder, including body dysmorphic disorder. And we need to carefully differentiate. Body dysmorphic disorder has to do with the person identifying a flaw that they perceive that nobody else sees, or a flaw that they perceive as huge and it's only minimally noticeable to other people. And in that case, they may engage in hair plucking if they think that there's a hair or something that is grotesquely growing out of their face or what have you, or if they believe that they have pimples or other things that are just grotesque to other people. That may be more in line with body dysmorphic disorder. Skin picking can include picking at pimples and scabs and other things like that. Like I said, we're not going to go deep into trichotillomania and excoriation. But it is important to note, when I was working in Florida, for example, when it would come time for the annual achievement testing, the annual state testing, the teachers would get stressed out, the kids would get stressed out, and we would inevitably. I can't think of a year that it didn't happen. We would inevitably see a few students engage in either excoriation or trichtillomania. They may not have known they were doing it. It may have been only minimally conscious of their behavior. But pulling out eyelashes while they took their test, or pulling out hairs on their arm, or pinching with their fingernails and making sores or lesions on their arms. Now this isn't non suicidal self injury, this is simply picking and squeezing at the skin. But those are behaviors that can exacerbate. They can become very problematic. And if they're in places where other people can see, they may become very embarrassing to the person. So we do want to recognize the importance of addressing some of these things. Differential diagnosis Hoarding disorder is pretty self explanatory. The person collects stuff and it significantly clutters and compromises their actual living space. And separation from that stuff causes them significant distress. And inability to collect more stuff may also cause them significant distress. So that's a little bit different than obsessive compulsive disorder. Trichotillomania is hair pulling and sometimes it's intentional. Sometimes the person will pull hairs and eat them, sometimes they will roll it around in their fingers. There are people who may do it very intentionally, but there are also people who do it relatively unintentionally. Same thing with excoriation, Body dysmorphic disorder. The focus is on a perceived flaw that is not observable or only minimally noticeable to others. We do want to recognize that they may spend hours a day trying to cover this up and engage in checking behaviors, but it's related to this one perceived flaw. Eating disorders, the focus is on food and weight. There is a restriction of caloric intake in anorexia and a disturbance in the experience of body shape or weight. They have a lot of obsessions about their body, about weight, about fear of fat, about fear of rejection. And the compulsive behaviors revolve around controlling body shape and controlling food intake. Illness Anxiety disorder is diagnosed when somebody has a preoccupation with having or developing an illness and engage in excessive health related behaviors like going to the doctor multiple times, seeing multiple physicians. It is less concerned with hand washing and what you might call home based rituals. There's more involvement of other people, multidisciplinary team. Differentiating some of these disorders. Eating disorders illness Anxiety disorder from obsessive compulsive disorder can be very tricky. And I would encourage you to, I personally would encourage you to really look at the symptoms that the person is experiencing. The diagnosis is there in order to potentially help guide treatment and so you can get reimbursement from the insurance company. The symptoms are what the person is dealing with and helping them address their presenting symptoms as they're presented instead of getting too caught up in a diagnostic label is important because what works in treating an eating disorder or ocd or hoarding disorder for one person may not work for another person. There is no one size fits all treatment. For each diagnosis. We need to make sure that we're individualizing other things that we need to rule out or rule in. There can be some comorbidity here. Generalized anxiety. With generalized anxiety, the person has a variety of worries, a variety of anxiety about a variety of things. Most of the time, okay? They typically don't have compulsive behaviors with them. But remember, in OCD you don't have to have obsessions and compulsions. So again, your diagnostic criteria gets a little bit dicey or differential diagnosis may get a little bit dicey here. Major depressive disorder, guilt and depressive ruminations. These things are mood congruent and tend to not be what you would call intrusive. They're not just having a great day and all of a sudden they have this intrusive thought. They're down in the dumps and they are feeling really depressed, apathetic, anhedonic. And they may have these persistent thoughts that are going through their head, but those thoughts will remit when the depression remits. Postpartum depression, and this one wasn't mentioned in the DSM 5tr. But I think it's really important to note that a lot of people, not the majority, but a lot of people who develop postpartum depression may have intrusive or scary thoughts. And as a result of those thoughts, they may engage in some compulsive compensatory behaviors in order to try to keep themselves and their infant safe. Treatment definitely important when the behaviors are ego syntonic, that is that these images they're having, they believe are true and real. That is an indication of postpartum psychosis needs immediate medical intervention. If their intrusive thoughts, their scary thoughts are ego dystonic, they're having these thoughts and they're like, no way I would ever do that. Or that makes no sense. That's an indication of postpartum depression. However, it is something that needs to be addressed so the person doesn't start a cascade of developing compensatory behaviors. There are treatments for that the ob GYN or their general practitioner or psychiatrist can help them with in order to manage the postpartum depression. Substance use disorders. There is a obsessive nature about substances and the compulsion to stop those cravings is to use. But this is not distressing, if you will. We're not having intrusive, distressing images. The person is obsessing about, hey, when do I get my next hit? Their dopamine levels drop and their body prompts a craving that leads them to compulsive behaviors in order to try to satisfy that craving. So it's different. Gambling and gaming disorder, very similar. We're still dealing with a dysfunction in the dopaminergic system, but the intrusions are about, I need to do this right now, I need another hit, not I need to do this in order to avoid something really, really bad happening. Schizophrenia spectrum disorders. People with schizophrenia spectrum disorders have other symptoms in addition to the obsessions and the compulsions and may not spend as much time engaging in those behaviors. So, yes, people with schizophrenia spectrum disorder may have some delusions and they may engage in compulsive behavior in order to try to prevent that from happening. But we also want to recognize that there is more to the diagnosis of schizophrenia spectrum disorders than just the delusions and obsessive compulsive behaviors. People with autism spectrum disorder may engage in a repetitive pattern of behavior. However, this is not in order to address obsessions. So they may have some compulsive habits that they engage in, but that's part of asd, or it can be part of ASD and they have other symptoms of autism spectrum disorder, which you're not going to see in people with obsessive compulsive disorder. Ptsd. Interestingly enough, there's a lot of overlap between symptoms of OCD and ptsd, like intrusive thoughts and doing things to avoid those intrusive thoughts or to make those intrusive thoughts go away. It's very common in PTSD as well as in ocd. So they found in this particular study of veterans that on a self report measure, 81% of the veterans met the criteria for PTSD and 74% met the criteria for obsessive compulsive disorder. Does that mean that this many people had both of these disorders comorbid, or does it mean that the sensitivity or the validity of the self report measures might be called into question because there is so much overlap between the symptoms and that a self report measure may not capture it accurately or adequately? I don't know. Looking at the research, a lot of the treatment for OCD and PTSD are very similar. So again, let's look at the symptoms and try to figure out what treatment strategies are best going to help this person address their particular symptoms. Another article I came across, and this is not in the DSM5TR either. Numerous drugs such as atypical antipsychotics, which reduce dopamine and dopaminergic agents Like L. Dopa, which increase dopamine, can cause or exacerbate OCD symptoms. Wow. All right, so you may be like, well, if I'm not dealing with somebody with schizophrenia, then it's irrelevant, right? No. A lot of atypical antipsychotics are prescribed off label for. For sleep related disorders and restless leg syndrome. And there's a variety of other situations in which atypical antipsychotics specifically may be used. Parkinson's disease involves disruption of the dopaminergic system. And in treating the Parkinson's disease, when the medications start altering the dopamine levels in the person's brain, you may see the onset of OCD symptoms. And that's definitely something that needs to be discussed with the person's doctor if they're. Especially if their primary diagnosis is Parkinson's disease and the symptom onset came right after or shortly after the beginning of a medicine treatment. Cocaine, opioids and amphetamines can also contribute to skin, especially skin picking. This is very common feeling like they've got bugs under their skin or being really itchy. If somebody has used cocaine or opioids or amphetamines and opioids, even those that are prescribed and taken as prescribed, some people may have a significant sensitivity and a strong reaction to them. Amphetamines and. I spelled that wrong, sorry. Also may be prescribed for things like adhd, for example. And some people may have a sensitivity to them that does cause skin picking. And it's important to recognize that and again differentiate medication induced OCD symptoms or trichotillomania or excoriation symptoms from non medication induced suicidality. Now this is really fascinating and really important for us to know people with obsessive compulsive disorder, the current suicidal ideation rate. So at any point in time, the suicidal ideation rate of people with OCD is 25.9%. So roughly 26%. Little more than one in four. That's a lot. Lifetime suicidal ideation is 44%. So for people who've had OCD at some point during their life, 44% have had suicidal ideation. Lifetime suicide attempts 14.2%. That's more than one in. That's more than one in 10. Yeah, it's hard for me to do math in my head while I'm talking. More than 1 in 10, though. Lifetime suicidal ideation in people with trichotillomania or excoriation is 40%. Attempts are right around 14%. It's important for us to recognize suicidal ideation for OCD and trichotillomania is in the 40 percentile area. That means almost half of the people that have this diagnosis are going to experience suicidal ideation at some point. We need to do a better job of screening for it in order to help provide them tools and a sense of hope and support. Body dysmorphic disorder has a lifetime suicidal ideation rate of 74.5%. And I know we didn't cover that a lot today. However, it's in this category and there is significant overlap with trichotillomania and excoriation disorder. Therefore, I think it's important to recognize that, that there is definitely a very high risk of suicidal ideation and suicide attempt rate of 35% which goes even higher if the person also misuses substances. That's a lot. If you're treating body dysmorphic disorder, it's not a diagnosis of vanity. It's not a diagnosis that you want to take lightly because especially in our society of Instagram and social media and everything else and the emphasis that's put on appearances, our society is very challenging for people with body dysmorphic disorder and you can see how very easily they could spiral into suicidal ideation, depression, hopelessness, helplessness. Hoarding disorder, interestingly enough, has a lifetime suicide attempt rate of 24.1%. Now it makes you think to yourself, I hope why is hoarding disorders attempt rate so much higher than ocd? What may have happened that predisposed the person to hoarding disorder or what may be going on in hoarding disorder that increases their suicidal ideation and suicide attempt rate so much comorbidities. Now these are things that co occur with obsessive compulsive and related disorders. 76% of people who have one of these disorders also have anxiety, 63% have depressive or bipolar disorder, 56% have an impulse control disorder, 39% have substance use and interestingly 30% have tic disorder. We want to assess for tics when we are doing our, when we're doing our intake. But it is important if we have somebody presenting with tic disorder that we also assess for obsessive compulsive and related disorders because they do go together 30% of the time. Treatment treatment for obsessive compulsive and related disorders is pretty straightforward I guess. SSRIs and SNRIs. As far as pharmacological interventions still seem to be the frontline treatment for or first line treatment for ocrds. The dosage tends to be much higher for for OCD than For other disorders. Cognitive behavioral therapy in terms of addressing the non neurochemical, if you will, symptoms that the person's experiencing. Backward chaining can be very helpful to encourage the person to identify vulnerabilities. What things happened that made you more prone to have these obsessions today? What things happened that led up to this particular belief? Exposure and response prevention or systematic desensitization can also be very, very helpful. If they have a compulsion to do something and they're prevented from doing it with appropriate tools, of course that is one of the most effective treatments. In order to help them through this process though, in order to help them tolerate the obsessions, in order to help them not engage in the compulsive behaviors, breathing is very important. Respiratory vagal nerve stimulation is what they call it, if you will, deep breathing. Deep breathing actually triggers the vagus nerve and the rest and digest which can help people tolerate the stress response when they have an obsessive thought and or are prevented from engaging in compulsive behaviors. Distress tolerance skills such as distress tolerant thoughts, activities that can help the person distract themselves, guided imagery to help them envision getting through a particular situation or envision a safe place and sensations like splashing cold water on their face can be helpful during this response prevention period. Unhooking is another thing that's helpful for both obsessions and compulsive behaviors. Unhooking means believing that this thought is not part of me. I'm having a thought, what am I going to do with that thought? This compulsion is not part of me. I don't have to act on it. I'm having the desire to engage in this behavior. I don't have to do it. What am I going to do with it? I have choice. Cognitive processing going back to REBT, we can look at the ABCs, the activating event, your beliefs about the event and the consequences, or you can go more towards the FCP area, encouraging the person to look at the facts for and against their belief, identify what they do and do not actually have control over, and explore the actual fact based probability of that their worst fear is going to come true. Cognitive restructuring can also be helpful with people, for example, who believe that if they don't wash their hands a certain number of times, they're going to get sick. They're probably going to get sick at some point. So cognitive restructuring can help them reframe that with I took precautions so I didn't get as sick as I could have. I kept myself as healthy as possible and it's highly Improbable to go your entire life without getting sick. Journaling can also be helpful, especially when you're going through that response prevention. Have them after the response prevention is over, have them journal or what it felt like to have the thought to not be able to engage in the compulsive behavior. And then how do they feel now even though they haven't done that, done that ritual or engaged in that behavior. Other treatment targets, common cognitive distortions and obsessive compulsive and related disorders include overestimation of three threat. This is where fact really comes in. Based on the facts in this situation, how likely is it that that bad thing is going to happen? An inflated sense of responsibility based on the person's what they do. How responsible are they for this? They may say if I don't do these six things then, then something bad is going to happen to my significant other. They're going to get in a car crash or something. So we need to take a look at that. Your significant other is driving the car. Your significant other is responsible for defensive driving. How much responsibility do you have for preventing them from getting in a car accident when you're not even in the car? Perfectionism is another cognitive distortion we need to address. How perfect does it need to be? We want to help people learn how to tolerate uncertainty. We want to help them examine whether having a belief is as bad as acting on it. A lot of people with obsessive compulsive disorder may believe that if they have this thought, they might as well have acted on it. Difficulty planning and organizing is another treatment target. This is more common in hoarding disorder, but not uncommon. And obsessive compulsive disorder and internalizing. I am responsible for these things. I am the one that did this. Personalizing, internalizing everything that happens. We want to help them unhook from those things and figure out who they are. Separate from their behaviors. They separate from things they have no control over. Negative emotionality and neuroticism refers to how people perceive what is going on in their world. And come over here, come over here, sit down. I'm sorry. Negative emotionality and neuroticism is another target because people who engage in this type of behavior tend to view things through a catastrophic lens. Instead of seeing things through rose colored glasses, they're seeing things through mud colored glasses. We need to help them reframe and embrace concepts like radical acceptance and also be able to view the entire picture. Get the entire picture. Not just a certain set of data and behavioral inhibition. A Lot of people with obsessive compulsive disorder have a history of intolerance of uncertainty. And it's important to help people develop their the skills and tools they need to be able to tolerate life on life's terms because there is a lot of uncertainty. And many times the compulsions are designed to help the person feel like they have a sense of control. Therefore, we need to help them figure out how can what can you do in life in order to cope with unexpected events? In order to cope with uncertainty. Up to 60% of people with OCD report sensory phenomena such as feelings of incompleteness that precede compulsions and just right sensations upon resolution. According to the research, incompleteness may result from internalization of the OCD and association with a baseline. This is what I do. This is what I've always done. If I don't do it, I don't know what else to do. Or they may have a lack of what one researcher called a stop signal. So they do something, but then they need to keep doing it because they never feel like they've actually finished or done it completely. The people with a lack of a stop signal tend to experience incompleteness for certain. They often don't experience the just right sensation. They never feel just right, which is why they keep perseverating in the behaviors. Obsessive compulsive and related disorders are extremely disruptive to the individual's life. It's important to use it's important to engage in early intervention for obsessed and compulsions, even if they're not requiring more than an hour a day to prevent exacerbation and development of comorbid issues. By the time somebody's engaging in compulsive behaviors more than an hour a day, it's already likely negatively impacting their life. They're getting less sleep, they're not engaging in health behaviors the way they should, they are not doing things at work the way they're supposed to, or they're late for work. It's negatively impacting their relationships because they're foregoing those things in order to engage in those compulsive behaviors or avoid things that might trigger the obsessions. Obsessive compulsive related disorders are often associated with a history of trauma. So attention must be paid to how the behaviors create safety, how treatment can empower the individual to create safety in different ways. Now, I didn't mention this on the treatment page, but if somebody does have identifiable trauma that they experienced, whether or not they believe it's connected to their ocd, or not, EMDR may be very helpful at helping them process those trauma memories. So they feel feel safer they can start processing their trauma sensations, their trauma reactions, which may help mitigate some of the obsessive compulsive behaviors.