Obsessive Compulsive Disorder and Addiction Awareness

All right, let's go ahead and get started. I'd like to welcome everybody to today's presentation on obsessive compulsive disorder and addiction awareness. I am your host, Dr. Donnelly Snipes. We are going to define obsessions and compulsions for those of you who haven't been working with that population very much. We'll define obsessive compulsive personality disorder and addiction, and we'll explore common obsessions and compulsions and their function, which is important. Explore why addiction often co occurs with OCD and identify interventions appropriate to assist people with ocd, ocpd, Obsessive compulsive personality disorder and addiction. So we've got a lot to cover. Obsessive compulsive disorder. Henceforth I will refer to it as ocd, obsessive compulsive disorder, impulse control disorders, and substance related disorders overlap on different levels, including phenomenology, comorbidity, neurocircuitry, neurocognition, neurochemistry, and family history. So you, you can find out more about that obviously by going to any of the links throughout the presentation that will give you more information about what we're talking about. Activity in the orbitofrontal cortex. You know, we always talk about that frontal cortex as being so important in impulse control. Activity in the orbitofrontal cortex is associated with cocaine and alcohol craving as well as obsessive compulsive disorder. So we know that there is a dysfunction in that particular area of the brain. Obsessions and compulsions are central characteristics of ocd, but also addiction. And you know, it's somewhat semantics when we're splitting between ocd and addiction sometimes, and we're going to talk about that more, especially when it comes to process addictions. But when you think about addiction, people with addictions, when they are not using, often obsess about getting that substance again and they have a compulsion to get it to stop their distress because, you know, not being able to access it not only produces physiological withdrawal, but it also produces psychological withdrawal and makes them more sensitive or more aware of their emotions and or physical pain, which often are things that they're trying to escape from in their addiction. This article, obsessive compulsive disorder, impulse control disorders, and drug addiction also proposed that impulse control and obsessive compulsive disorders may acquire qualities of the other with time. So people who have obsessive compulsive disorder may start acquiring characteristics of people with addictions and vice versa. I thought that was sort of an Interesting supposition. Compulsivity in OCD and addictions is related to impaired dopamine and serotonin release. Remember, dopamine is that chemical in our brain that says, I've got to have it. I want to go after it again. I want to do that again. And serotonin is one of our modulating neurochemicals that is associated with. Associated with. When it's in the accurate balance is associated with contentment. When serotonin is too low or too high, we end up seeing mood disorders. But interestingly enough, we also see compulsivity. And one of the things we're going to talk about in several slides is the fact that the serotonin we're talking about here, often they're referring to 5ht3, which is not the same serotonin that we often talk about in relation to mood disorders, which is 5ht1 and sometimes 5ht2. So remember, there are multiple different types of serotonin receptors out there, but the one that's often most associated with OCD and addictions is 5ht3. And different medications work on different serotonin transmitters. Treatment of these disorders must address alterations in the underlying motivations, such as experiential learning. When somebody has obsessive compulsive disorder, we know that in many cases it started out with a fear of something, and then that became generalized. So we need to address their underlying motivations for these thoughts and these behaviors. What's the function? Same thing for addiction. Why is the person using? What is the benefit to them to using? And what are the neurobiological issues that need to be addressed? With ocd, OCPD, and addiction, we see a imbalance in neurotransmitters. Unfortunately, with any and or all of those we can't easily put our finger on, it's definitely this one all the time for everybody. There are multiple neurotransmitters that are involved specifically, most often dopamine and or serotonin. But GABA has also been implicated, as has glutamate. So let's talk about obsessions. Obsessions are disturbing, recurrent and persistent thoughts. If I don't check the door, something bad's going to happen. Or impulses. I must wash my hands or I'm going to get sick. These obsessions are intrusive. We occasionally will have thoughts. You know, I'll be laying in bed, getting ready to go to sleep, and I'm like, did I remember to lock the door so I may get up and do it but then I go lay back down and I'm like, I'm good. People with obsessive compulsive disorder have difficulty feeling confident that the doors are locked and everything is okay. Sometimes they feel like they've got to do things in ritualized fashion, sometimes in sets. You know, I have to check it three times or I have to do the, this certain, do things in a certain way in order to make sure it's right. People may have obsessions about germs, taboo thoughts. They may have those thoughts come up in their head frequently. Aggressive thoughts or a need to do particular behaviors to prevent harm. I worked with one client many, many years ago who had very detailed rituals that he needed to go through every single day in order to prevent harm from befalling him or his family. And these rituals, every single time he went through them, would take an hour and a half, two hours. And if he messed up, if he made a mistake and did something out of order or not quite the right way, he had to start all over again. So oftentimes this young man was stuck, was paralyzed and stuck in his house because it, these rituals took so much time out of his day. The thoughts in obsessive compulsive disorder do not focus exclusively on real problems. You know, we can, for example, with the pandemic, a lot of people are focusing a lot and thinking a lot about how to prevent getting sick and what they need to do. They're paying a lot of attention to germs. Now this can be overgeneralized at a certain point and can spiral out of control for some people. And it's important to recognize that. But a lot of times obsessions, you know, like we talked about with checking the stove or checking, checking the doors or washing your hands, focus on things that are improbable to happen, not something that is highly likely to happen. We want to differentiate when we're talking about obsessive compulsive disorder, we want to differentiate it from generalized anxiety eating disorders, where somebody obsesses about their weight, fat and what they eat. Addiction, PTSD and postpartum depression. We're going to talk about those on Thursday when we talk about co occurring issues with obsessive compulsive disorder. But it is important to recognize that there is a lot of overlap. There are a lot of conditions that do have some obsessional compulsive characteristics to them. In obsessive compulsive disorder, the person attempts to ignore or suppress the thoughts or impulses by doing something often, and they are aware that these thoughts, impulses, and images are a product of their own mind. They are in tune with the fact they recognize that their mind is creating this situation. So I really encourage you to think about how these characteristics apply to addictive behaviors. So disturbing, recurrent and persistent thoughts or impulses that are intrusive, Especially when someone is in recovery, they may have cravings, and these cravings can be frustrating. And they may develop a ritualized set of behaviors that they do to prevent using. The person attempts to ignore or suppress the thoughts or impulses. And in addiction, there are a variety of things people do, and they are aware that that's from their own mind. What are the functions of these thoughts? A fear of germs. Let's just start with that one. That's one of those really common obsessions people have. What is the function of this protection? When someone feels in danger, when they feel powerless, when they feel threatened in some way, they may try to create behaviors and. And do things in order to protect themselves. And, you know, again, these behaviors can generalize. And we need to look back to where is this stemming from? Where did this anxiety start, and how did it spiral to the point that it did? In what ways has this person felt disempowered and unsafe in their environment, in their life? And how does this behavior make sense? Common obsessions in relationships, people may obsess about. You know, if I enjoy when my partner is away, maybe I really don't love them. Or sometimes I look at other people and I think about cheating. Maybe I secretly want somebody else. Sometimes my partner looks at other people. Maybe they want somebody else, or my partner hasn't texted me all day. They must be cheating on me or not want me anymore. When these thoughts become obsessional, when they just are intrusive, it's the only thing the person. Well, primarily the. The only thing the person can think about. You know, they just. They can't focus because their mind keeps going back there. It's starting to cause problems in their functioning. So that's when it kind of starts rising to the level of an obsession. Harm obsessions, including, if I drive on a bridge, I might just take the wheel and turn it a little bit, drive off and kill everybody in the car. If the doors aren't locked, somebody will break in and kill us. If I didn't turn off the stove, we'll have a fire and die. If I'm around other people, I'll get sick and die. There are a lot of these fears that we can really trace back to unsafeness. And powerlessness. And we've talked about something else that's happened before. Trauma causes feelings of unsafeness and powerlessness. I'm not saying that all trauma causes ocd. You know, we don't see that connection. But there is a possibility that traumatic events can cause ocd. Health obsessions. And there are a lot of them, but one of the more common ones is, oh, I have this pain. What if it's cancer? What if I'm going to die? And, you know, there are people who fret over every single freckle that they get over every single pain that they have, and it can consume their life. And a lot of times when people have those. When people have health obsessions, then they turn to behaviors to try to reverse or address those things. Sometimes they're logical, like improving their nutrition, but sometimes they are not as logical. You know, maybe if I do these six things, if I read this book, if I'm nicer to people, then it'll go away. So let's talk about compulsions. Compulsions are repetitive behaviors or thoughts that the person feels driven to perform to prevent or reduce distress or to keep something bad from happening. And we've talked about that a little bit. The symptoms of obsessive compulsive disorder are not the result of another psychiatric disorder presentation or caused by a medical condition or substance abuse. Cravings are what we talk about in substance abuse, though. Cravings can be very obsessional. People can obsess over wanting their drugs, feeling they need to have their drugs in order to prevent feeling overwhelmed and, you know, diabetes. Somebody can have diabetes and be very focused on what they are eating and their blood sugar. You know, that that's a legitimate, actual problem, actual present issue that they've got to face every day in their life. So it's normal and helpful for them to be aware of that. Unless it starts becoming so. The. The obsessions start becoming so present that the person can't think about anything else. They're all. They're checking their blood. Blood Sugar, like, every 20 minutes throughout the day. That's obviously not going to be helpful. Crohn's disease is another one of those physical issues that can prompt some obsessional thinking and compulsions. People with Crohn's disease may. May fear that if they eat something, it's going to upset their stomach. And they may be extremely focused on every single thing they eat. And it consumes. You know, again, it consumes their. Their. Their life. Common compulsions include comparing your partner to others or comparing yourself to others. Frequent breakups or needing frequent reassurance. You know, obviously that's in relationships, in with harm compulsions, frequent checking, washing, or isolating to keep yourself safe from all that stuff or prayer. Now, none of these things in moderation is bad, don't get me wrong. It's when it goes to the extreme with health concerns, nutrition may be an issue, or detoxification through exercise, diet, or things like, you know, staying in the sauna for extreme periods of time in moderation, not necessarily bad things in excess, it can be debilitating and in general, magical thinking with rituals and mantras. If I do this three times, if I walk on these three steps every single day, I will have a good day. And we see a little bit of this in superstitious thinking. You know, if you think that there is, you know, I'll admit I have a lucky scarf, and I know luck doesn't exist. And if I looked at, you know, the statistics, it wouldn't pan out. But whatever, you know, it doesn't harm me. I don't have to have it with me all the time. But we. I think a lot of us have certain superstitions that we. We have that in and of itself, that's kind of in moderation. But if your life is consumed by rituals such as, when I get up, I've got to do these 17 things before I can eat breakfast, or, you know, I'm going to die, or bad things are going to happen, then obviously that's a problem. And generally the threshold that I've heard a lot of people talk about is rituals that consume more than an hour a day. But, you know, it can go a little bit either way. Definitely an hour or more is really probably starting to negatively impact people's lives. And Pat has a good point. Sometimes things like lucky scarves or I also carry my rosary around with me can be comforting to us. They can be grounding objects. They can be comfort objects, transitional objects that help us feel more comfortable. If it isn't something that is negatively impacting your life in a significant way, then there's probably nothing wrong with it. And it's important for people to remember that all of this stuff is on a continuum. People will have obsessions from time to time, like right now. But remember, the pandemic is ever present, and we're focusing on that a lot right now because it is currently a threat and it is an actual threat in our life, as opposed to thinking about, you know, if somebody's obsessing, you know, all day, every day about nuclear war. Yes, it could happen, but right now is that how likely is that to happen like tomorrow? And you could argue with either way on that. But people also can't control that nuclear war is going to be something that happens politically, geopolitically, and it's not something that an individual can necessarily do anything about. But I digress. Obsessive Compulsive Personality Disorder is different than ocd. It is a pervasive pattern of preoccupation with orderliness, perfectionism and control in a variety of contexts beginning by early adulthood, as indicated by four or more of the following they're preoccupied with details, rules, lists, order, organization or schedules to the extent that the major point of the activity is lost. Now, as I go through each of these, I want you to think how does each one of these address safety and or power? How does it help somebody feel safer or more empowered to protect themselves in their life? Shows perfectionism that interferes with task completion. Is excessively and unnecessarily devoted to productivity to the exclusion of recreation. Is over conscientious and inflexible about matters of morality, ethics or values not accounted for by culture or religious identification. Is unable to discard worn out or worthless objects even when they have no sentimental value. I cling to that last part because I have a lot of sentimental stuff that I still have. But I digress. It is reluctant to delegate tasks or work with others unless they submit to exactly their way of doing things. Adopts a miserly spending style and shows rigidity or stubbornness. Now this sounds like a person with control issues, but what is the crux of control? The crux of control is protecting oneself from harm. Perfectionism and needing to have things your own way may be a way of trying to protect yourself from failure. What happens if we fail? Well, maybe that person grew up and got the messages that if you fail, you are not lovable, you will be rejected. Being over conscientious and inflexible about matters of morality, ethics or values. Again, could be something that came from messages that they got when they were younger that taught them extremes and you're only lovable if you are perfect in this way. So we want to go to some of those core values and core messages that people have to identify what is making them feel unsafe and and what is making them feel powerless to the extent that they feel like they have to control most things most of the time. And yes, it is possible for the environment to contribute to intergenerational transmission of obsessive compulsive disorder as well as Obsessive compulsive problems, personality disorder. There is a lot of nurture that happens in this environment. Remember, if you think back to the cognitive behavioral triad, our thoughts, our feelings and our behaviors all interact and any one of those three things is going to alter the neurotransmitter balance could be for good. You know, you could have positive thoughts and positive feelings and positive behaviors and positive neurotransmitter balance. But people, for example, I was talking about this in my live presentation earlier. People, for example, who are taking medication for anxiety, for example, but they're still having all of these anxiety provoking thoughts and they're still engaging in behaviors or exposing themselves to environments that trigger their anxiety, they're working against that medication because those thoughts are triggering the HPA axis and triggering norepinephrine and glutamate to be, to be released. And so they're kind of working against the medication. It's important to remember. My point being that yes, we've seen that there is a neurotransmitter imbalance, especially in the orbital orbitofrontal cortex. However, that could be genetic or it could be caused by a, from a history of stressful thoughts and trauma or anxiety. Not, I'll say again, not everybody who experiences trauma will develop OCD there. We don't have that connection. But it is important to recognize that our experiences and our thoughts can alter our neurotransmitters. And if we're in an environment that is exceedingly stressful and we see our parents, you know, we learn. So social learning theory go back to bandura. We see them coping with their stress and in these ways, then we are probably going to grow up thinking this is the way we're supposed to cope. Figured I would share this with you guys. Many, many years ago, my daughter says to me, mommy, Shawn put a plastic bowl in the cabinet with the glass bowls. And I looked at her and I said, that sounds an awful lot like tattling. Is there a purpose for telling me that? She responds without missing a beat. Yeah, I like seeing your nervous tick face. It's like, really? So, yeah, I shared that because I, my friends who know me got a big kick out of that one. We all have things that make us a little bit stressed, but it's a matter again, a matter of degree. You know, some people have to have all of their labels for their cans turned a certain way and, you know, excessive order and they spend a large amount of time ordering and cleaning things every day. Others of us, we just have bins we have the glass cabinet and the plastic cabinet. So looking at what that communicates, looking at whether it is reasonable, is really important. So what do we do? Medications for addiction, which modulate dopamine and medications for OCD often overlap. And we want to look at medications that modulate the dopamine system through the opioids, like buprenorphine and naltrexone. They actually work not only on the opioid system, but the dopamine system. Glutamate, serotonin, again, 5ht3. So that's not going to be your standard antidepressants like your Prozac and your Zoloft.5HT3 is going to be a different type of serotonin reuptake inhibitor and gaba, all of these. And it's important to recognize when you alter one, you alter all of them. So when you alter GABA for some people, you make dopamine balance out. So we've got to figure out what is causing the dopamine or the serotonin to be out of balance. What else is going wonky here? And obviously we're not prescribers, so that's what the psychiatrist is going to do. But treatments of these disorders must account for the alterations in the underlying neurobiology of the condition. For example, people with substance use disorders and impulse control disorders may respond best with naltrexone because that blocks certain pathways. Topiramate may be helpful for people with comorbid impulse control disorders and eating disorders. And obviously, topiramate works on the GABA system. We while naltrexone works on the opioid system. So there are differing things that we need to look at. What do we do, though, as counselors, as clinicians, as social workers, what can we do? Explore when the OCD or OCPD and the addiction began. We want to look back and figure out when did these behaviors really start? Start, see if there was a precipitating incident and work forward from there to try to figure out how it became generalized. That's really important. We know, for example, people with panic disorder may start out with having a panic attack, and then eventually it generalizes to the point where they are agoraphobic because they're so afraid that if they leave the house, they're going to have a panic attack. So we do want to look at when it began so we can identify the precipitating event and get some context. Identify in what ways the OCD or the OCPD and even the addiction address feelings of unsafeness you know, how does this help you feel safer? How does it help you feel calmer? The reason they engage in the compulsions is to reduce the anxiety. The reason people use substances or behavioral process addictions is often to reduce emotional distress. So we want to ask them, how do these behaviors help you feel safer or calmer? Encourage them to develop a checklist of ways the behaviors help them feel safer. That way you can start addressing them. So checking the door helps you feel safer because. And then you can start addressing cognitive distortions associated with those thoughts. Encourage them to practice journaling and exploring the probability that something bad will happen. Silly me. Yesterday I had to take a package. It got misdelivered to our house. I had to take it over to a neighbor's house. And when I got back to my house, I jumped out of the car and walked into the house leaving my keys in the car. So I spent like 20 minutes looking for my keys this morning because I couldn't find them, but I had left them in the car. Now, could something bad have happened? Could somebody have gotten into my car and driven away with it? Yep, sure could have. Did it happen? No. How probable is it to happen out in rural, extremely rural metro Nashville area? Not super probable. So that's good. So I don't lay awake in bed at night thinking, is somebody going to steal my car tonight? It's important to journal what my thoughts are. You know, if. If I'm working with somebody with OCD or ocpd, encourage them to journal what their thoughts are and explore the probability that the worst case scenario is actually going to happen. I think a lot of us have left the house at some point and thought to ourselves, did I remember to turn off the stove? Okay, well, that could become an all consuming thought if you don't check it against probability. I can't even light a piece of paper on fire to start a candle on our stove. We have one of those, you know, ceramic top stoves or whatever, it doesn't get that hot. So the chance number one, the chances that I left the stove on are pretty small. The probability that I left the stove on is pretty small. The probability that I left it on and something on it would catch fire is almost minuscule. So those are. Checking against the facts is really important. And addressing each thought with probability and facts that something's going to happen. Another thing people can do is reach out to a support person. It's important when people are feeling unsafe sometimes when that obsessive thought is going through their head to just call Somebody and start talking maybe about something completely different so they can break that cycle of that repetitive thought. Protect. How does, how do these behaviors protect from rejection or failure? We want to explore people's beliefs surrounding rejection and failure. We want to help them enhance their hardiness and improve their self esteem. Now, that is, the rejection and failure themes are a lot more common with obsessive compulsive personality disorder. But you do see some of these themes in OCD itself. We want to look at that. Nobody loves rejection or failure. So we want to look at what messages people received when they were growing up, where these messages came from, and how valid are they. What happens if you do something and you get rejected? You know, is that the end of the world? Let's what, follow the thoughts to their completion all the way through the catastrophizing, if necessary, and then explore the facts supporting those and against those, those beliefs and the probability that that would happen. With hoarding, for example, a lot of people may hoard because they're afraid that if they throw this away, they will need it again. Could that happen? Well, maybe. But can you find the information somewhere else? Now, you know, God bless him. My husband still has some of his notebooks from high school. We're both 50 years old now. But he, you know, kept saying that I may need him one day for to teach the kids, or I may need them one day for whatever. And my response was always, we've got the Internet now, but, you know, we pick our battles. But that's the beginning of hoarding for people. They start making justifications for everything, and then that stuff literally starts piling up and taking over their, their physical spaces. I do have a very interesting interview I did with a woman who wrote a book on hoarding on the YouTube channel. So if you're interested in learning more about hoarding, it's called clear the clutter. But you can check out that video. She was, you know, very informative. We had a very interesting and engaging discussion. When we're talking about addiction, again, we want to ask, how does it help the person? Let's talk about pornography addiction, for example, or compulsive gambling. You know, how does this help the person? If the person starts, you know, obsessing about, about pornography or obsessing about gambling, why are they engaging in these behaviors? What is it? What need is that serving for them? Is it protecting them? Giving them something else to focus on besides the mess that is their life? Or is it helping them focus on something else? We need to identify the underlying motivations to help people figure out a more functional way of meeting those same needs. Use chaining to explore how the addiction relates to obsessive thoughts that trigger cravings and compulsions or using for addiction. So maybe somebody has a fear of germs which produces anxiety. Well, they're going to have obsessions that you know about that fear of germs. And they will have this compulsion to do something. When they do that something, it's relaxing. It's like ah, which is the, the body's secretion of, of GABA and those calming neurotransmitters. So behaviors can prompt that relaxation effect, that. Relief that they're looking for, which is why it may go to, you know, doing whatever that compulsive behavior is, whether it's using or doing something else. Sometimes people have, well, encourage people. I usually put this up on the board. What is your thought or the situation? You know, let's talk about what this obsession is. What are your feelings right now when you're having that thought? What are your feelings? What are your urges when you're having those thoughts and feelings? So now we're looking at thoughts, feelings and behaviors. What are your urges and what is the function of those urges? How is it that washing your hands six times can help? How is it that drinking or gambling can help address this situation? And many times it's helps the person, quote, feel better. And we want to look at other ways to help them feel better. We want to learn about distress intolerant thoughts. I do this. I have a lot of distress intolerant thoughts written on different index cards, old school. And I put them in a hat or a box. And I have people draw what a distress intolerant thought. Like I am going to die if I don't or I can't stand this or I am going to go crazy. All of those thoughts that tell us that we can't cope, that we are unsafe. People draw a distress intolerant thought and then they need to make a alternate style self statement such that instead of saying I can't stand this, saying something like this is really unpleasant right now. However, I have gone through worse things or it'll be over shortly. Teach people ocd, OCPD and addictions. They all have urges, you know, that compulsion and helping them learn to ride the wave. You don't have to act. I had one woman that I had in group that had to wash the dishes every night. If there was a dish in the sink, it drove her crazy. And she. Her words, not mine. And we had we talked a lot about urges and riding the wave. We looked at the underlying thoughts. Why was it that having that dish there bothered her so much? And ultimately it came from her upbringing. But learning to tolerate that glass in the sink or that fork in the sink and being able to look at it and go, you know what? Nothing bad is going to happen if that sits there. It took a while, but she did make amazing amounts of progress. She was very motivated to do, to do the work on it. Encourage people to learn about unhooking. And this is a component of acceptance and commitment therapy. Instead of saying I must wash this dish right now, she could have said, I am having the third thought that I must wash this dish right now. Thoughts we know we can argue with. If I say I must, it feels like it's more attached to me. So if I unhook and I make it a thought, then I can disregard a thought. Teach people distress tolerance skills. When they are having these obsessive thoughts, it's important that they can engage in thought stopping when they have that anxiety built up and they're feeling distress. Compulsions are designed to eliminate or reduce distress. Distress intolerant thoughts or distress tolerance skills are also designed to relieve distress. So we're helping the person develop skills to replace their other behaviors for when we get into exposure and response prevention. Identify and develop a plan to mitigate triggers or vulnerabilities for the ocd, the ocpd, or the addiction. Encourage people to be aware of what causes it for you and how can you manage these things. Sometimes they may find that their OCD is worse at certain times of year, at certain times of day, if they haven't gotten enough sleep, if they're around certain people, there are a lot of variations. So we want to help people identify if there are any triggers or vulnerabilities that they can mitigate. Journaling is really important in recovery from this. And it doesn't have to be long form journaling. They can bullet, bullet, point it, whatever. Now one of the things I do for this is a beach ball activity. And you can get these little cheap beach balls at the dollar store. And I take a permanent marker and I write more than that on mine. I write a lot on mine. But the first ball is common. Triggers for obsessions and compulsions or obsessive compulsive personality, disordered behavior, the hypervigilance, the need to control everything. So I put common triggers on the ball. I throw the ball to people in the class, they grab it. Whatever they look at, whatever they See, first they read that trigger and they talk about, you know, why might this be a trigger for obsessions or compulsions and what else might somebody be able to do in order to deal with it. Same thing I do another beach ball. Common triggers for addiction. But the third group we have, we talk about the similarities between triggers for OCD and addiction. So this is a three, three group series that we do to help people really start seeing what might be causing it and brainstorming and getting better at coming up with solutions or interventions on the spot that they think might work. Address cognitive distortions that contribute to distress. A lot of times I will use colored Jenga blocks and each Jenga block represents a different type of cognitive distortion. So when they pull an orange one, it represents mind reading. And they have to tell me a time when they used mind reading and it increased their anxiety and discuss how they could use facts, finding exceptions or looking at the probability versus the possibility in order to address address mind reading. And with mind reading, a lot of times it comes down to facts. We don't know what somebody else is thinking. Mindful awareness activities can help improve self awareness of people's increasing anxiety or anger levels. So they can promote early intervention. Or when they notice that they're starting to feel anxious about something they can use, they can have an anxiety thermometer that they regularly check in. I encourage people who are in early stages of developing their skills to have it as the lock screen on their mobile device. And it doesn't have to have the little faces with it, but that way every time they pick it up to look at their mobile device, they are confronted with that thermometer and they are prompted to check in with themselves. Psychological flexibility is another one. And you can use, I've gotten away from, you'll be happy to hear from using flip chart paper in the four corners of the room. And I've got four dry erase boards, one in each corner of the group room. And with psychological flexibility, you have people identify behaviors that will help them be happier, be calmer, be more content. Thoughts that will help them be happier, be more content and behaviors that they currently do, like their compulsions that don't help them in the long run be happy, healthy and content and behavior and thoughts and feelings that in the long run don't help them to be happier, healthier and content. So you know, you have those four stations and you encourage people to. Or I encourage people to go around to each station and just in general first talk about things that they can do that can help them Feel safer and more empowered? What things can you do? What thoughts can you have? And then obviously the opposite. What things can you do or thoughts can you have that make you feel unsafe? And then, then I'll give them a specific issue, like germs that may be a common theme for people in the group, and then they go around and do that same thing to address a specific issue. What positive behaviors can I do to allay my anxiety and keep myself healthy and safe? What positive thoughts can I have in relation to germs and getting sick? What positive thoughts can I have that help me move forward and have the life that I want to have? And exposure and response prevention. I get into that a little bit later, into treatment. It is the gold standard for treating OCD and helping people tolerate cravings. However, I really like to make sure that people have some foundation, support skills to identify and tolerate their distress and alternate behaviors that they may have hypothesized to deal with the issue before I kind of put them in this. In this exposure situation. Now, I will note that when you're working with addictions, we're talking about tolerating cravings. We're not talking about exposure, exposure therapy with addictive substances. I don't want someone with an alcohol use disorder going to a bar and doing this. No, that is bad. Definitely don't want to do that. But for example, with. With addiction, you might talk about, you know, when you're feeling a craving, what thoughts are you having? You know, because people will have cravings whether they're exposed to the actual addiction or not. And then they can work through it that way, Encouraging people to think the thought or about the decision about the situation and describe how they feel. Do this in session. You know, we don't want them to just, you know, like the lady with the. With the dishes in the sink. We. We don't want her to just go home and, you know, I want you to go home and, you know, when the dishes are in this thing, just do something else and tolerate it. That. That's cruel, in my opinion, you know, so we will do it in session. First, we'll talk about, you know, what is it like for you? And I will share, you know, to kind of piggyback off that one, I guess. When I was little, my grandmother always said, always would take her shower at night and put on makeup and perfume before she went to bed. Because she said that, you know, if something bad were to happen and the police were to come or the fire department were to come, she didn't Want to be unpresentable. And I remembered that that kind of imprinted in my psyche. And my husband was in law enforcement for many years and when he was on midnight shift, I remember not being willing to go to bed with the house a mess or I wouldn't want to look completely gross, like having conditioner in my hair and a face mask on or something. Because I knew that the one time I did that and I was not presentable, something bad was going to happen. Now was that logical? No. Was that superstitious thinking? Oh, yes. But you know, I did. It did bother me, you know, if I lay down to try to go to sleep because I was worried that, okay, that'll be the day that, you know, I get that knock at the door. And that was something that I had to deal with and learn to cope with. Thankfully, all I had to do was, you know, clean the dishes and make sure I didn't stink and I was good. So it wasn't something that took an inordinate amount of time, but it is, it was an obsessive thought that would keep me awake if, if I didn't do it. So, you know, encouraging people to identify their thought or their situation and describe how they feel, you know, so if I was talking about, you know, how I felt when I was lying in bed and he was at work and the kitchen was a mess, what are my feelings, what are my thoughts? And then practice re regulation and distress tolerance activities. When prevented from engaging in that behavior, deep breathing, talking to a support person, they will have, hopefully they will have pre made a list of things that they can do instead of engaging in that compulsive behavior. But encouraging them to do that in session, walking them through it until they can, I call it, reregulate until they can get their breathing and their heart rate down and they don't feel as anxious, they don't feel like they're going to crawl out of their skin if they don't do whatever it is. But again, I will say, please don't use exposure therapy with addictions. To the extent that you're exposing them to their addiction of choice, that, that's, you know, bad, bad stuff. What all. All I'm talking about is helping them learn how to tolerate cravings through response response prevention. They're having a craving. It doesn't mean that they have. There is significant overlap between OCD and OCPD and addictive behaviors. And we do need to recognize that because people with OCD and OCPD are at a much greater risk for developing addictive behaviors. And we need to be sensitive to that, partly because they have similar issues or similar changes in that orbitofrontal cortex. I can't say that today for some reason, but partly because people who are struggling with the anxiety that comes with OCD or OCPD may find some relief from addictive behaviors, and we do want to be sensitive to that. Treatment involves identifying the underlying thoughts, exploring what is contributing to fears of unsafeness, whether it's harm, rejection, loss of control, and powerlessness. Identify the function of those thoughts and behaviors. In what way are these compulsions keeping you safe or helping you reduce your anxiety? Practice exposure and response prevention to decondition the compulsive behaviors. Practice it in session and then, you know, gradual exposure in homework assignments. So for the example, the client I worked with that had the issue with having dirty dishes in the sink, you know, initially I would have her see if she could tolerate the dishes being in the sink for five minutes. And then we went up to 15 minutes, then 30 minutes, then only washing the dishes once after breakfast and once after dinner. But it was a gradual progression and potentially considering medication to help rebalance the neurotransmitters, especially until the brain can adapt and reroute those neural networks, address the anxiety. You know, there's anxiety issues in the amygdala that need to be addressed. Some people, a lot of people, from what I was reading, I don't work with OCD a lot in my practice. The. The research seems to indicate that a lot of people with OCD are going to be on medication for a long period. But that's not necessarily everybody in terms of aging. Excuse me. As we get older, a lot of times our cognitions and our cognitive abilities become less flexible. So sometimes people may get. Become more. Develop more behaviors that are similar to obsessive compulsive personality disorder. You know, going to my grandmother's house, I remember things had to be just so or it would cause her immense amounts of stress. But a lot of that is because our cognitions slow down, because we don't. We're not as responsive as quickly. It's that way. There are no surprises and they feel safe. But yeah, that's a great question. Are there any other questions? Alrighty, everybody. Have a great day. I'm going to end it right here because I'm not going to stop coughing. And I will see you on Thursday. You. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. A direct link to the on demand ceus for this podcast is@allce.com podcastceus that's allce.com podcast ceus to sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week. 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