Obsessive-Compulsive & Anxiety Disorders
Let’s go!
Why these conditions?
The conditions I treat are all related and likely to co-occur. You only have one? Lucky you! You have multiple? Join the club! The treatments are super similar (mostly ERP with a few tweaks) so we’ll still be efficient and prioritize making a small number of impactful behavior changes.
Obsessive-Compulsive Disorder
About 90% of my clients have OCD, and they are logical, thoughtful, brave, accomplished, delightful human beings. OCD isn’t a character flaw! It’s part of the hand some of us were dealt. Not even the worst possible hand, when you think about it.
“Do you treat people with my type of OCD?”
Sure do! I have treated:
Cancel culture OCD: What if I get canceled? Time to review everything I’ve ever said/written/done
Contamination OCD: Our famous friend! You have a rationale, and yet that’s an impressive amount of cleaning
Existential OCD: After we die, then what? Am I real? Am I doing life right? Can’t make decisions until I know
False memory OCD: What if I killed or sexually assaulted someone, or cheated, and then just forgot?
Gender identity OCD: I think my gender identity is xyz…but what if I’m lying? I should feel 100% sure!
Harm OCD: I could theoretically just snap and stab someone! Better avoid all sharp objects from here on out
Hit-and-run OCD: Am I 100% sure I didn’t run someone over? Let’s circle the block and check
Illness anxiety/hypochondriasis: Technically a separate diagnosis, but acts a lot like OCD.
Intruder/break-in/danger fear: Just what it sounds like!
Just right OCD/perfectionism: This doesn’t feel quite right. Moving on anyway? Negligence! I’ll just do a bit more
Magical thinking: I had a bad thought about my mom. Will it kill her? I should replace it with a correct thought
Mental health OCD: What if I secretly have xyz mental condition? What if I develop all the other types of OCD?
Meta OCD: Is this really OCD? The right treatment? The right therapist? Am I doing my exposures right?
Moral scrupulosity/Hyper-responsibility: Could I have theoretically hurt his feelings? K, I’m a horrible person
Musical/other meaningless intrusions, or repetitive thoughts we try to push out of our heads, leading to…more
Pedophilia OCD: Aw, cute kid! Oh no, am I a pedophile? Let’s avoid all kids to keep them safe, including mine
Perinatal OCD: Not a standalone subtype, but OCD can flare up, even in parents who are not carrying the baby
Pregnancy OCD: What if I get pregnant from hugging my friend? From swimming? From a toilet seat?
Pure O: Not diagnosed anymore! Mental compulsions = compulsions. Look for your themes in this list.
Racism OCD: Will I randomly shout/type a racial slur? What if I did, but just forgot? Oh no, avoid everyone!
Relationship OCD (romantic or platonic): Is my partner 100% right for me? Do my friends secretly hate me?
Real event OCD: Did that joke I made during my toast go one step too far? Did I contribute to their divorce?
Religious scrupulosity: Did I say the prayer with the right thought in mind? I should redo it. Am I going to hell?
Sensorimotor OCD: I’ll always notice my blinking/breathing/spine alignment. Ah, blinked again! This is torture!
Sexual orientation OCD: I think I’m straight/gay/whatever. Do I know? Do I need to break up with my partner?
Suicidal OCD: What if I randomly kill myself? Even though I don’t really want to? OMG I sound crazy
Violent/sexual obsessions; taboo thoughts: These thoughts are unacceptable - must never have them!
Whatever type of OCD you have, the treatment is the same.
We design exercises to help you take reasonable precautions, then mindfully tolerate the remaining possibility that bad things will happen anyway.
I thought I couldn’t do it either! Yet here we are.
Body Dysmorphic Disorder
The argument:
You cannot be happy as long as your appearance “flaws” remain. Even if they saw you 10,000 times before, other people might eventually notice, and will see you as disgustingly ugly or deformed from then on. So whatever stands out to you, you have to make sure it’s fixed or hidden, otherwise there’s no way you can be present - metaphorically, and sometimes literally. ERP probably doesn’t sound super safe to you - why would you expose your flaws to the world and put all your goals in jeopardy that in any way depend on other people have a positive opinion of you?
The reality:
It’s true that you have a lot more fears about trying ERP, compared to people with OCD or any of the other conditions I treat. That is totally fine and expected, and is built into treatment for BDD. We will only proceed to exposure exercises when you’re ready, and we will do as much “pre-exposure” therapy as you need. Basically, that means examining your arguments around your appearance decisions, including premises, logic, and conclusions. We will note any issues, correct them, and then try again to see what you really think. I will often offer alternative premises and logic, but you are the one who ultimately decides what you think is accurate, using your logical brain. ERP is then taking the next step and putting your predictions to the test, so your reptile brain can also come to its own conclusions. Again, we will only do that when you say go.
Want more background on BDD treatment?
I can’t recommend this book highly enough: Feeling Good about the Way You Look: A Program for Overcoming Body Image Problems. BDD isn’t easy to live with before treatment, but we finally live in a time where we know what it is and have the option to change if we want to. As someone living with well-treated BDD, I have a lot of gratitude for the resources and people who helped me get where I am today, and I derive a lot of meaning from participating in other people getting better as well.
Body-Focused Repetitive Behaviors
Skin picking (excoriation disorder), hair pulling (trichotillomania), excessive nail-biting, and so much more
The argument:
You won’t be able to tolerate not picking, pulling, rubbing, scratching, biting, etc. The urges will never fade, so you may as well give in. Life might be boring and unbearable without the soothing upsides of your BFRB. At the same time, you’re the one voluntarily choosing to engage in these behaviors, and they’re weird and embarrassing. Therefore, you’re a freak for not stopping sooner.
The reality:
Just because you have been doing something for a long time doesn’t mean you can’t change. It doesn’t even mean that change is particularly hard. What it does mean is that every time you tried to stop in the past, you were using strategies that were never going to work.
Habit Reversal Training & Comprehensive Behavioral Treatment (HRT/ComB)
You’ve tried to stop a lot of times and in a lot of ways, but let’s try an evidence-based treatment specifically designed for BFRBs. It’s similar to ERP format-wise, and in both treatments, you’re learning you can tolerate urges. They actually come and go rather quickly if you respond mindfully! We identify the thoughts, situations, emotional states, and other factors that precede BFRB episodes. We problem-solve how to respond to those triggers in ways that make you feel good before AND after. Then we set up practice exercises, see what worked and what didn’t, and keep modifying until you’re where you want to be. Tada! Less picking, pulling, scratching, etc. For real this time.
Anxiety Disorders
Illness Anxiety
You worry you will get cancer or another life-altering diagnosis, then suffer horribly and maybe die—or worse, that will happen to the people you love. You might always regret dismissing the early signs. You spend hours Googling symptoms to figure out how worried you should be. Health is important, so you can’t promise to cut out the research altogether, but you recognize this whole cycle is excessive.
Panic Disorder
No one knows when the next panic attack will strike. You worry about having one in class, at work, while driving, on an airplane, on a date, during an interview, and everywhere else it would be inconvenient or embarrassing. On top of that, they feel awful. It’s hard to remember you’re not dying when it genuinely feels like you can’t breathe or are having a full-blown heart attack.
Phobias
Death, serious injury, or extreme discomfort and humiliation could be just around the corner, unless you diligently avoid things like:
Bats, bees, dogs, snakes, spiders, or even all animals
Heights, open or enclosed spaces, the ocean, planes, cars, storms, fires
Throwing up, choking, sex, dental care, needles
Social Anxiety
Public humiliation: a fate worse than death. You avoid all kinds of situations in which you are supposed to “perform” or follow some invisible script and act “normal.” (Public speaking? No thank you.) You also do tons of catastrophizing about all the ways you could theoretically embarrass yourself, which makes the lead-up to all kinds of social events quite painful.
These are different starting points in terms of main fears and typical compulsions. However, the journey and the destination are the same: ERP until your symptoms reach “subclinical levels,” meaning your distress and impairment is pretty close to everyone else’s. And yes, the prognosis for all of these conditions is good if you actively engage in treatment. Make sure to review the page on ERP if you haven’t already.
Misophonia & Misokinesia
They’re not in the OCD family, but I treat them because they often co-occur with the conditions above. Plus, I have misophonia as well, and I like helping people who struggle with the same things I did.
What are misophonia and misokinesia? Misophonia or “selective sound sensitivity syndrome” and misokinesia appear to be sound and motor processing disorders that cause strong irritation in response to specific sounds or motions.
What is their impact? First, there’s the physiological experience of sudden jolts of irritation. Second, there’s mental distress. Common thoughts: avoiding my triggers makes my life small and sad but enduring them feels excruciating, I’m just being dramatic and this is all in my head and I need to try harder to relax, if I ask people for any change on their part they’ll think I’m princess-y and it will damage the relationship, and the kicker: there is nothing I can do to make any of this better; I’m stuck in an awful cycle and life sucks.
Are these conditions a real thing? Yes! At least according to the American Medical Association, American Psychiatric Association, American Academy of Audiology, Duke University, Harvard University, National Geographic, 23andme…you get the picture.
Is there an evidence-based treatment? Not yet. Misophonia research is just getting started, so rigorous testing hasn’t happened yet for any one treatment. If anyone insists they have an “evidence-based treatment for misophonia,” they likely mean “scientific reasoning was semi-involved in design or testing.” The real bar is much higher. It means a treatment was repeatedly tested for effectiveness while also carefully avoiding known causes of inaccuracy, such as the “I invented this treatment so of course it works” bias. In the meantime, we have an array of both well-reasoned and truly wacky approaches.
How do you approach treatment? My approach is similar to this case study from UCSF, and can be described as “CBT for misophonia.” Unlike with all the other conditions I treat, your initial response to your triggers is not expected to change. Therefore, we focus on problem-solving the downstream effects. We make modifications to your lifestyle and skill set so you 1) are exposed to triggers less often 2) feel more prepared to efficiently and effectively respond when you are exposed 3) stop reinforcing negative thoughts about yourself, other people, and your ability to enjoy your life. There are no studies yet that speak to average expected symptom reduction. All I can say is that mine barely factors into my life anymore, and I’m hoping for the same for you.
The other main approach is ERP, which I do not use for misophonia. Minimal exposure to the sounds can be useful when we are practicing specific skills (politely requesting accommodation, calmly putting in earplugs and moving away, mindfully shifting attention repeatedly to other stimuli) even when feeling angry, disgusted, or panicked. However, I do not think exposure results in growing any less sensitive to the sound. I love ERP; I just don’t think it works for this condition, which is a position shared by some (but not all!) misophonia providers and organizations.
Where can I get more information and connect with people like me?
Duke Center for Misophonia and Emotion Regulation
Reddit (yes, just scroll wisely as always)
You will never be 100% sure
& it will never be the perfect time
True, the idea of starting treatment comes with its own scary “what ifs.” But what if all that happens is that you get better? You could quit your unpaid internship as an aspiring professional worrier, continue to be the responsible human being you always have been, and have time to live in the moment and think happy thoughts.