real life case study of ocd

A True Story of Living With Obsessive-Compulsive Disorder

An authentic and personal perspective of the internal battles within the mind..

Posted April 3, 2017

• What Is Obsessive-Compulsive Disorder?
• Find a therapist to treat OCD

Contributed by Tiffany Dawn Hasse in collaboration with Kristen Fuller, M.D.

The underlying reasons why I have to repeatedly re-zip things, blink a certain way, count to an odd number, check behind my shower curtain to ensure no one is hiding to plot my abduction, make sure that computer cords are not rat tails, etc., will never be clear to me. Is it the result of a poor reaction to the anesthesiology that was administered during my wisdom teeth extraction? These aggravating thoughts and compulsions began immediately after the procedure. Or is it related to PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infection) which is a proposed theory connoting a strange relationship between group A beta-hemolytic streptococcal infection with rapidly developing symptoms of obsessive-compulsive disorder in the basal ganglia? Is it simply a hereditary byproduct of my genetic makeup associated with my nervous personality ? Or is it a defense tactic I developed through having an overly concerned mother?

The consequences associated with my OCD

Growing up with mild, in fact dormant, obsessive-compulsive disorder, I would have never proposed such bizarre questions until 2002, when an exacerbated overnight onset of severe OCD mentally paralyzed me. I'd just had my wisdom teeth removed and was immediately bombarded with incessant and intrusive unwanted thoughts, ranging from a fear of being gay to questioning if I was truly seeing the sky as blue. I'm sure similar thoughts had passed through my mind before; however, they must have been filtered out of my conscious, as I never had such incapacitating ideas enter my train of thought before. During the summer of 2002, not one thought was left unfiltered from my conscious. Thoughts that didn't even matter and held no significance were debilitating; they prevented me from accomplishing the simplest, most mundane tasks. Tying my shoe only to untie it repetitively, continuously being tardy for work and school, spending long hours in a bathroom engaging in compulsive rituals such as tapping inanimate objects endlessly with no resolution, and finally medically withdrawing from college, eventually to drop out completely not once but twice, were just a few of the consequences I endured.

Seeking help

After seeing a medical specialist for OCD, I had tried a mixed cocktail of medications over a 10-year span, including escitalopram (Lexapro), fluoxetine (Prozac), risperidone (Risperdal), aripiprazole (Abilify), sertraline (Zoloft), clomipramine (Anafranil), lamotrigine (Lamictal), and finally, after a recent bipolar disorder II diagnosis, lurasidone (Latuda). The only medication that has remotely curbed my intrusive thoughts and repetitive compulsions is lurasidone, giving me approximately 60 to 70 percent relief from my symptoms.

Many psychologists and psychiatrists would argue that a combination of cognitive behavioral therapy (CBT) and pharmacological management might be the only successful treatment approach for an individual plagued with OCD. If an individual is brave enough to undergo exposure and response prevention therapy (ERP), a type of CBT that has been shown to relieve symptoms of OCD and anxiety through desensitization and habituation, then my hat is off to them; however, I may have an alternative perspective. It's not a perspective that has been researched or proven in clinical trials — just a coping mechanism I have learned through years of suffering and endless hours of therapy that has allowed me to see light at the end of the tunnel.

In my experience with cognitive behavioral therapy, it may be semi-helpful by deconstructing or cognitively restructuring the importance of obsessive thoughts in a hierarchical order; however, I still encounter many problems with this type of technique, especially because each and every OCD thought that gets stuck in my mind, big or small, tends to hold great importance. Thoughts associated with becoming pregnant , seeing my family suffer, or living with rats are deeply rooted within me, and simply deconstructing them to meaningless underlying triggers was not a successful approach for me.

In the majority of cases of severe OCD, I believe pharmacological management is a must. A neurological malfunction of transitioning from gear to gear, or fight-or-flight, is surely out of whack and often falsely fired, and therefore, medication works to help balance this misfiring of certain neurotransmitters.

Exposure and response prevention therapy (ERP) is an aggressive and abrasive approach that did not work for me, although it may be helpful for militant-minded souls that seek direct structure. When I was enrolled in the OCD treatment program at UCLA, I had an intense fear of gaining weight, to the point that I thought my body could morph into something unsightly. I remember being encouraged to literally pour chocolate on my thighs when the repetitive fear occurred that chocolate, if touching my skin, could seep through the epidermal layers, and thus make my thighs bigger. While I boldly mustered up the courage to go through with this ERP technique recommended by my specialist, the intrusive thoughts and compulsive behaviors associated with my OCD still and often abstain these techniques. Yes, the idea of initially provoking my anxiety in the hope of habituating and desensitizing its triggers sounds great in theory, and even in a technical scientific sense; but as a human with real emotions and feelings, I find this therapy aggressive and infringing upon my comfort level.

How I conquered my OCD

So, what does a person incapacitated with OCD do? If, as a person with severe OCD, I truly had an answer, I would probably leave my house more often, take a risk once in a while, and live freely without fearing the mundane nuances associated with public places. It's been my experience with OCD to take everything one second at a time and remain grateful for those good seconds. If I were to take OCD one day at a time, well, too many millions of internal battles would be lost in this 24-hour period. I have learned to live with my OCD through writing and performing as a spoken word artist. I have taken the time to explore my pain and transmute it into an art form which has allowed me to explore the topic of pain as an interesting and beneficial subject matter. I am the last person to attempt to tell any individuals with OCD what the best therapy approach is for them, but I will encourage each and every individual to explore their own pain, and believe that manageability can come in many forms, from classic techniques to intricate art forms, in order for healing to begin.

Tiffany Dawn Hasse is a performance poet, a TED talk speaker , and an individual successfully living with OCD who strives to share about her disorder through her art of written and spoken word.

Kristen Fuller M.D. is a clinical writer for Center For Discovery.

Facebook image: pathdoc/Shutterstock

Kristen Fuller, M.D., is a physician and a clinical mental health writer for Center For Discovery.

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Home / Blog / Obsessive Compulsive Disorder – Sophie’s story

Obsessive Compulsive Disorder – Sophie’s story

Sophie is a 26-year-old mental health advocate who has lived with OCD for 11 years. She won a Bill Pringle Award with Rethink Mental Illness for her poem on managing OCD in 2019 and has spoken publicly about her experience on radio and on social media. She is open and vocal about mental health and mental illness because she knows first-hand how isolating and scary it can be in the beginning.

“I just felt guilty all the time about every small thing that, before OCD, wouldn’t really have bothered me at all, and I needed people to tell me I was a good person.”

Obsessive compulsive disorder

OCD is a chronic and potentially debilitating mental health condition in which an individual has uncontrollable (“obsessive”) thoughts or images and compulsive behaviours that can be distressing, frightening and upsetting.

The myths that annoy me – and the truth about them

Ocd is characterized by the desire to keep yourself and/or your space clean..

False. While the compulsion to clean isn’t unheard of among individuals with OCD, cleanliness and OCD aren’t mutually exclusive and the compulsion to clean shouldn’t be considered a choice or desire. Instead, they may feel that it is mandatory in order to find relief.

Everyone is “a little bit OCD.”

False. You cannot be a “little bit” OCD. OCD isn’t an adjective – it’s a complex disorder that affects only 1-2% of people and can be incredibly difficult to manage without the appropriate treatment and care.

OCD can be cured.

False . While this may sound daunting, OCD can be effectively controlled and managed with treatment that suits the individual, allowing them to live a healthy, happy life.

My symptoms When my OCD first started I thought it was simply anxiety, but after doing some research into mental health I realised it was OCD. I felt guilty and paranoid for most of the day with very little relief, overthinking every little bit of whatever thought or image was in my head at the time. I would wake up with palpitations and struggle sleeping because I couldn’t stop ruminating. Logical thought takes a back seat with OCD. When your brain wants to convince you that you’re a bad person, it will give you lots of evidence to try and support it. When you don’t know how to fight back, it can be truly terrifying – you’re defenceless.

My lowest moments I began to worry about leaving the house because I couldn’t determine what situation might trigger another intrusive thought, and that lack of control over your own thought process can completely take over your daily life. When I did leave the house, I would avoid the people or things that were involved in my thoughts, otherwise I struggled to cope. I would experience the same recurring intrusive thought or image for months at a time and would only find (albeit short-lived) peace when I was completely distracted.

I haven’t experienced many compulsions, but my primary one was reassurance-seeking or “confessing.” I constantly felt guilty for my thoughts and at my lowest point, when it became overwhelming, I would find myself asking my mum or partner to remind me that I am a good person, but my brain didn’t seem to want to believe it. It was a terrifying circle – an intrusive thought would come in, I’d panic and ruminate, find someone to “confess” to and the process would start all over again. This lasted for a number of years before I discovered that it was only making my OCD worse.

My way forward After two failed attempts at seeking help via public and private mental health services, I admittedly haven’t been very lucky with professional help and so had to learn to manage my OCD on my own, with the additional support of a select few trusted friends and family. As such, I trained in mental health first aid and undertook a lot of personal research, not only to help myself but to help others like me. I’m the nominated mental health champion at my place of work, though I generally remain a passionate advocate for mental health in all aspects of my life, and I will continue to help others for as long as I possibly can. I also love to write and have found solace in writing about my OCD via reflective poetry.

Why I’m sharing my story When I felt my lowest, when I felt there was no escape, it wasn’t professional help that ultimately helped me but the experiences of others with OCD or who know about OCD. It was the advice of mental health charities, the blog pages of people with lived experience and the never-ending stream of support I had that helped me to help myself. I’m very proud that I can now manage my OCD successfully and, if I ever find myself feeling low or overwhelmed, I know that I can overcome it. I see my OCD as an enduring and experienced reflection of myself – it is no longer a threat.

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Real-life mental health stories: suffering from OCD

Posted on May 13, 2019 December 31, 2019

This blog post is part of an interview series for mental health awareness week. In this series, different people give their perspective on living with a mental health condition.

In certain cases as with the interview below, people have had the courage to share but were not comfortable revealing their identity. For this reason, the interview is anonymous.

Who are you and why did you decide to share you story?

I am 37 years old, live in Amsterdam and am still trying to find out how to live life to its fullest

I work in sales for a global firm. What I sell doesn’t interest me that much, it’s more the social and intellectual environment from which I get my drive. As a matter of fact, my lack of interest in the topic sometimes leads to me feeling detached from work. On the one hand it gives me a feeling of freedom,  and on the other it makes me feel rather down and insecure at times. Who knows, this might have been undermining my mental health for a while…

I have a condition called obsessive compulsive disorder, more widely known by way of its acronym: OCD .  For me specifically, it asserts itself in mortal fear of toxic poisoning through my daily surroundings; both in- and outside, wherever, whenever. The effect is that I try to “defend” myself by, for instance, holding my breath, avoiding certain cycling/walking routes, specific locations and washing my hands excessively.

The first time it revealed itself  (in a slightly different form) was just before I turned 18. I got professional help at the time and then managed my OCD very well for the next 18 years (with ups and downs of course).

However, the last 18 months my OCD and its effects became progressively worse until it controlled my (emotional) life fully and I hit rock bottom, end of 2018.  

In any case, having read Emma’s blogs , I decided to reach out to her on the topic of mental health. This felt like a support and a relief to me.

When was the first time you became aware you were suffering from a mental health issue?

As mentioned above, I first suffered from OCD when I was 18. Most recently, I became aware that for the first time in 18 years my mental health was deteriorating again, before I actually approached my boss to say I was suffering from a mental health problem. During that year, all became progressively worse.

What were you feeling/what did you experience that made you aware of it? 

For my most recent experience, the concrete signs that made me aware my mental health was deteriorating included forgetfulness, really loathing the smallest chores, and a total lack of desire to do anything. Also, I just felt more and more frustrated, drained, short-fused and down… This led to an increased sense of estrangement from my surroundings and from myself.

From my surroundings, because my world became confined to my fears, but also because I thought no-one would really understand what was going on inside of me. Furthermore, I felt like a failure for not being able to fully function, neither socially, nor in my job. The sense of estrangement from myself was induced by this total incongruence of what, in my mind, I thought I should be (excellent start) and what I was: a total wreck. The result was that I started feeling very down and so alone.

What was your job at the time? 

At the time, I was working in my job as sales leader for a relatively new region. I had to develop a new book of business against a specific set of financial and behavioral KPIs. All in all, this role was a challenge but also meant a lot of autonomy – an aspect which gave me a lot of energy.

What was the relationship of your job to the mental health problems?

My OCD slowly but surely affected my ability to do my job. I lost focus, had much less energy, became very negative and started to cut corners. My productivity and results clearly suffered, which made me feel guilty and useless and in turn, made me more stressed. The increased stress just aggravated my mental health condition: a real vicious circle…  In the end I was so usurped by my OCD that I really didn’t care anymore about my job. That may also explain why I finally broke down during a totally unrelated and external event.

Interestingly enough, the deterioration in my mental health coincided with a slight shift in role, which led to less autonomy and more differences in opinion with my boss… However, it is really difficult to say what affected what or which one was the catalyst

What did you do about it?

Only once I broke down did I admit and accept I needed help. My OCD had literally taken over my life and was affecting everything, including my work.  I went to my boss to let him know that I needed help and my personal health was now top priority.

I chose to stay at work to continue with a daily routine that also forced me to be sociable. Simultaneously, I set out clear limits and agreed with my boss to drop some parts of the role such as traveling, which caused me anxiety due to my OCD.

I also plucked up the courage (sounds totally ridiculous, but this is what it felt like) to use my vacation time during the most important – and also stressful – period at work. This perhaps wasn’t to the liking of my boss, but certainly necessary for me and my recovery. Of big support in all of this was the fact that I fully opened up to a trusted colleague in the meantime, who showed me support.

The little bit of energy all of the above left me with, gave me the opportunity to focus on organizing professional help outside work.

How do you feel now? How did taking those steps make you feel, and have they helped?

Acknowledging and accepting that I really wasn’t doing well, sharing this with my boss and one other colleague, really helped me along the way. Moreover, accepting that OCD is part of me, that it’s ok to get professional help, and that I really felt a very strong urge to get on top of myself again, led to my recovery.

What are your lessons learned with regards to mental health, and work?

Work can both alleviate and aggravate a mental health condition. I say this is because

The effect work has on me is ambiguous. On the one hand, continuing to work forced me to get up and go out. It created routine, a little bit of distraction, and forced me to be sociable (as I like social environments). On the other hand, the work itself created stressful situations (including traveling for, but also to and from work) which made me more anxious, thereby aggravating my mental health situation. All in all, work for me meant keeping a grip on things.

  What are your next steps?

I just “successfully” completed an intensive exposure program for people with OCD. Next steps for me include continuing regular exposure to the specific fears I suffer from. Of course sometimes I really have to push myself, but it really helps to have a goal! I also plan to do more structured physical exercise since a combination of high cardio and walking helps me.

Most importantly I have made it a priority to be very aware of stressful activities or periods which may affect my mental health. I try to manage these by either keeping them to a minimum or at the least mentally prepare for how they may affect my well-being .

What would you like to say to someone who is suffering in silence from a mental health issue?

I have accepted professional help and re-gained energy to overcome my obsessive fear and related compulsions, specifically through “exposure therapy”. I also fully accept that OCD will most likely be a mental health issue all my life and that in the end, I am the only one (with or without help) who can manage this.

I decided to share my story because I really appreciated reading about other people’s (including Emma’s) experience with mental health issues, be it at or outside of work. Of course no one is the same, and there were many small but important thought processes I had to go through, as well as steps I had to take that were specific to my situation. But the fact that some people could possibly relate better to how I felt already made me feel slightly less alone.

Suffering in silence is very lonely. If you know at least one person you think you can share your mental health problem with (even if they might not completely understand), I recommend you do so. For instance, if you feel like reaching out to me sometime, feel free to contact me via Emma . 

Otherwise reading books and blogs of others who suffer – not necessarily the same issue – can be a form of support. Most importantly – try to accept your issue and don’t shy away from professional help, however long it might take before you feel better.

I hope my story can be of support to all those who are looking for some.

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Currently working in marketing and comms in Amsterdam. Passionate about all things digital, writing, dancing, travelling and much more. Mental health blogger and advocate. View all posts by emmacdo

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Real Event OCD: What It Is and How to Cope

Julia Simkus

Editor at Simply Psychology

BA (Hons) Psychology, Princeton University

Julia Simkus is a graduate of Princeton University with a Bachelor of Arts in Psychology. She is currently studying for a Master's Degree in Counseling for Mental Health and Wellness in September 2023. Julia's research has been published in peer reviewed journals.

Learn about our Editorial Process

Florence Yeung

BSc (Hons), Psychology, MSc, Clinical Mental Health Sciences

Florence Yeung is a certified Psychological Wellbeing Practitioner with three years of clinical experience in NHS primary mental health care. She is presently pursuing a ClinPsyD Doctorate in Clinical Psychology at the Hertfordshire Partnership University NHS Foundation Trust (HPFT). In her capacity as a trainee clinical psychologist, she engages in specialist placements, collaborating with diverse borough clinical groups and therapeutic orientations.

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

On This Page:

Real Event OCD, also known as Real Life OCD, is a unique subtype of obsessive-compulsive disorder ( OCD ). People who suffer from Real Event OCD will experience unwanted, obsessive thoughts and fears around an actual event that occurred in the past.

Individuals with Real Life OCD become fixated on actual events or past experiences that make them question their character or morality or made them believe that they are not good or ethical people. 

They might replay the event(s) over and over again in their heads, scrutinizing every detail, reciting every word they said, and analyzing any harm they may have caused through their actions.

“For the past 3 years my life has been hell ruminating over things I did/thought as a teenager, and I feel as though I’m putting up a facade whenever I interact with people. Like I’m some awful criminal with terrible secrets I need to hide. I hate myself. Logically, I know that what I did wasn’t that bad, but I just can’t convince myself.”

People who suffer from this type of OCD often overestimate the importance of their actions, and if they can’t clearly remember every detail of what happened, they are likely to assume the worst. These obsessions cause significant anxiety and distress, thus creating an urgent need to seek answers or reassurance.

As a result, people with Real Event OCD will engage in ritualistic and repetitive behaviors known as compulsions to repress these thoughts and reduce the anxiety caused by their intrusive thinking.

Like every other type of OCD , the more you seek certainty, the less certain you will become. While the compulsive actions will provide a temporary sense of relief, this feeling is short-lived because new doubts or questions tend to re-arise soon thereafter. 

Real Event OCD Obsessions

Obsessions often take the form of repetitive, persistent ideas,  unwanted or intrusive thoughts , images, or impulses that are experienced as distressing.

Common examples of Real Event OCD obsessions include:

• Worrying that you said or did something bigoted or offensive
• Fearing that you acted inappropriately
• Fearing consequences from your actions, such as being punished, canceled, or caught
• Worrying that your actions have caused others harm
• Feeling that you may have been critical, inauthentic, or unfair
• Worrying that your thoughts or actions make you a bad person
• Having intense, overwhelming feelings of shame, guilt, fear, or embarrassment
• Believing you are a terrible person because of your past actions 
• Experiencing intrusive thoughts, images, memories, or flashbacks about what happened
• Believing that you deserve to be punished for your actions

What Events Can Trigger a Real-Event Obsession?

There are an endless number of events that could trigger a real-event obsession. 

The event could be something minor, such as making a rude remark to a customer service representative or cheating on a test, or something more major, like driving drunk or making a racist comment.

Essentially, any event that makes someone fear they are a bad person can trigger these obsessive thoughts. 

Other examples include: breaking up with a significant other, cheating in a relationship, having sex with someone who seemed reluctant, plagiarizing on an assignment, or stealing.

They can be focused on a recent event or something from far in the past, such as stealing from a store as a child many years ago.

Real Event OCD Compulsions

Compulsions are repeated patterns of ritualistic behaviors, used to reduce anxiety and prevent an outcome, following a strong obsessive urge to do so.

Common examples of Real Event OCD compulsions include:

• Seeking punishment for your actions
• Repeatedly analyzing your past behaviors and actions, looking for wrongdoings or evaluating the terribleness of the actions
• Confessing or unnecessarily apologizing for your perceived wrongdoings in the hope of gaining forgiveness
• Excessively seeking reassurance from friends and family that you did not do anything wrong and / or that you are not a bad person
• Looking for ways to prove to yourself that you are a good person
• Calling authority figures, such as police officers or lawyers, to inquire about the potential consequences from your past actions
• Reimagining the event the way you would have liked it to go
• Criticizing and berating yourself because you believe you deserve to be punished for your past behaviors
• Trying to repent by doing “good deeds”

Real Event OCD is made up of three components: 

• The Event: What really happened E.g., I took LSD with my college roommate. He became paranoid. A few years later, he was diagnosed with schizophrenia.
• The Obsession(s): The intrusive thoughts about what happened. These are usually irrational or exaggerated. The individual may exaggerate the significance of the event, believing that it defines their entire character or that it will have long-lasting consequences on their future. The person might feel intense guilt and shame for taking drugs with their roommate, even if they have faced the consequences and learned from their mistake. It is my fault he is schizophrenic. I am a bad person. I caused this to happen.
• The Compulsions(s): The actions taken to try and gain temporary relief or reassurance.  The individual may ruminate on the event, constantly thinking about it and seeking reassurance from others about their actions. E.g., Researching schizophrenia and its causes; asking others who were there if they thought the person seemed reluctant to try the drug; replaying the details of the event in your mind to see if you had peer pressured him; trying to remember if you noticed any previous signs of mental health illness in the friend.

Do I Have Real Event OCD?

It is common for everyone to reflect on past events occasionally and wonder whether we should have done or said things differently. 

We might even berate ourselves about something we said or did that we wish we had handled more effectively, or experience momentary guilt over the consequences of our past behaviors. But, these reflections and feelings often fade over time without much rumination or distress. 

Someone with Real Event OCD, on the other hand, will spend hours over-analyzing, fixating, and ruminating on past events. 

They will replay events repeatedly in their head and excessively seek reassurance from others to gain a sense of certainty that they did not do anything wrong and are not a bad person. This process of engaging with the thoughts indicates that it may be OCD.

These individuals often find themselves trapped in the past, unable to engage in the present moment. They suffer from excessive feelings of guilt, shame, doubt about their actions, and an overwhelming sense that they are immoral or shameful. 

They will find themselves in a never-ending quest to find certainty and relief, but this relief is always short-lived as additional doubts and fears seem to be constantly regenerated in their minds.

Real-Life Personal Experiences

It was bearable for a large part of those years, only coming up every once in a while. This summer and into December, it was the worst it had ever been. Constant feelings of I am a bad person, how can I live with the mistakes I have made, you know the deal if you have real event OCD.”

“This cropped up for me the other day. I had a small verbal confrontation with someone while out with my daughter for March break (they failed to stop at pedestrian stop and then chose to honk and complain to me about it.) I kept replaying it throughout most of the day. Did I respond right, was I wrong, etc.”

“I am still scared of death and sometimes I am afraid that If I don’t do something, something bad will happen to someone I love or to me. I had some bad experiences with OCD. One of them was when one my friend’s dad died and the thoughts made me think that it was my fault because I didn’t do something that my brain wanted to.”

How to Manage Real-Event OCD

Someone with Real Event OCD will exert much energy and time to try and find certainty around a past event, making it very difficult to live and embrace the present moment.

OCD can be treated and managed effectively. You can learn to manage how your symptoms affect your daily life through medication, therapy, mindfulness, or a combination of treatments.  

Self-Management Techniques

In addition to seeking professional help, people with OCD can practice several techniques in their daily lives to manage their obsessive thoughts.

One of the problems with OCD is people treating their intrusive thoughts as enemy, not accepting them:

• Challenge Your Assumptions and Feared Stories → Try to use your most logical and rational mind to reconsider the importance placed on feelings, certainty, and the likelihood of a catastrophic outcome. Ask yourself: “What are all the things that would need to happen or line up for my fear to be true? How likely is it that all those things would line up just like that? Are there other areas of life where I am able to make decisions or move forward while accepting uncertainty and letting go of the need for perfect assurance?” This exercise will hopefully help you gain the confidence that the feared outcome is highly unlikely and help you realize that continued rumination will not bring you any closer to certainty.  However, it is also common that people with OCD may still struggle with their compulsions despite their rational mind knowing their feared outcome is not proportionate to reality.
• Make a Real-Event OCD Compulsion Inventory → One of the first things to do in OCD treatment is to make a list of all your compulsions. This list should include both external actions, like asking others for reassurance, and internal thinking patterns like mentally replaying the event over and over. With your therapist, you will then progressively work to minimize and eliminate these from your life. The hope is that as you stop the compulsions, you will be able to see that you can deal with the memory of the event and the presence of the guilt without performing compulsive actions.
• Accept Imperfection of Character , Self-Compassion→ Most individuals who suffer from Real Event OCD struggle with questioning their morality and character. They become stuck in a cycle of self-doubt and uncertainty and will sacrifice significant time, energy, and effort to regain a sense of assurance and worth. There is no winning with OCD because no matter how good you try to be, your anxiety and mistrust will always tell you to do more. We must practice self-compassion, telling ourselves that we are enough and allow ourselves to feel loved despite our mistakes and imperfections. 
• Turn Shame into Guilt → A good place to start is to practice shifting any shame-based language into guilt-based language. Observe how you talk to and about yourself in relationship to the event(s) in question. Shameful thinking will only cause you to experience more isolation, guilt, and self-criticism; but you can change and improve these intrinsic thoughts. Guilt thinking instead focuses on the actions you took and the decisions you made. Practice acknowledging your actions for what they are and set them apart from your character. For example, if you catch yourself saying things like “I am a terrible person” or “I deserve to be punished for what I did,” try to re-frame this to “I feel terrible for what I said” or “I should not have done that because I put someone else in danger.” 
• Turn Guilt into Self-Compassion → Once you are able to turn your shame-based language into guilt-based language, you can then work on shifting this guilt into self-compassion. This involves understanding that all humans make mistakes, and we all have something that we regret or wish we would have done differently. We should take responsibility for our actions while also allowing for forgiveness. We must resist the urge to continuously condemn ourselves for our past errors, and instead, offer ourselves compassion for being imperfect and making mistakes. 

Exposure and Response Therapy

As with all OCD subtypes, Exposure and Response Therapy (ERP) is a type of CBT considered the first-line psychotherapy for OCD.

At least half of the people who seek treatment for OCD will show symptomatic remission over the long term and experience an increased quality of life and improved functioning.

The best outcomes occur in individuals who are diagnosed early and start an intense treatment program right away. Depending on the severity of OCD, some people may need longer-term or more intensive treatment. 

In ERP , a person works with a therapist to identify both external and internal triggers that cause them stress and make them want to behave compulsively. ERP is designed to gradually reduce the anxiety that feeds the obsessions and compulsions through a process called habituation.

The goal of habituation is to purposely invoke anxiety in attempts to disrupt the neural circuit between the processing and action parts of the brain.

In the case of Real Event OCD, a common form of ERP therapy is to use an imaginal exposure script. Imaginal Exposure involves vividly imagining the feared object, situation, or activity. The goal is to create a first-person, present tense, detailed narrative of the worst-case scenario occurring.

By writing out the story as it happened, as specifically as possible, people can learn that catastrophes are less likely than they expect and that they can cope with the catastrophe if it ever does happen.

As part of this exercise, you can also draw a picture of the location, the event, or the person involved, or listen to music that makes you think of the time.

Pozza, A., & Dèttore, D. (2019). “Was it real or did I imagine it?” Perfectionistic beliefs are associated with dissociative absorption and imaginative involvement in obsessive-compulsive disorder.  Psychology Research and Behavior Management , 603-607.

Rosso, G., Albert, U., Asinari, G. F., Bogetto, F., & Maina, G. (2012). Stressful life events and obsessive–compulsive disorder: clinical features and symptom dimensions.  Psychiatry research ,  197 (3), 259-264.

Vidal-Ribas, P., Stringaris, A., Rück, C., Serlachius, E., Lichtenstein, P., & Mataix-Cols, D. (2015). Are stressful life events causally related to the severity of obsessive-compulsive symptoms? A monozygotic twin difference study.  European psychiatry ,  30 (2), 309-316.

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Living With O.C.D. in a Pandemic

Covid made things worse for many people with obsessive-compulsive disorder. But it also came with a silver lining.

By Jane E. Brody

Most people behave in one or more ways that others may consider peculiar, and I am no exception. I want my clothes to match, from shoes to eyeglasses and everything in between (including underwear — a challenge when packing for a trip). If visitors use my kitchen, they’re asked to put things back exactly where they were found. In arranging my furniture, countertops and wall-hangings, I strive for symmetry. And I label packaged foods with their expiration dates and place them in my pantry in date order.

I know I’m not the only one with quirks like these that others may consider “so O.C.D.,” a reference to obsessive-compulsive disorder. But the clinical syndrome, in which people have unbidden recurring thoughts that lead to repetitive habits, is far more than a collection of quirky behaviors. Rather, it is a highly distressing and chronic neuropsychological condition that can trigger serious anxiety and make it difficult to function well in school, at work or at home.

For someone with O.C.D., certain circumstances or actions that most people would consider harmless, like touching a doorknob, are believed to have potentially dire consequences that require extreme corrective responses, if not total avoidance. A person may so fear germs, for example, that shaking someone’s hand can compel them to wash their own hand 10, 20 or even 30 times to be sure it’s clean.

For many, the Covid-19 pandemic only made things worse. Past research has found a potential correlation between traumatic experience and increased risk of developing O.C.D. , as well as worsening symptoms. A person with O.C.D. who already believes dangerous germs lurk everywhere would, understandably, have become paralyzed with anxiety by the spread of the novel coronavirus. And indeed, a Danish study published in October found that the early months of the pandemic resulted in increased anxiety and other symptoms in both newly diagnosed and previously treated O.C.D. patients aged 7 to 21.

How serious is O.C.D.?

The disorder often runs in families, and different members can be affected to varying degrees. Symptoms of the condition often begin in childhood or adolescence, afflicting an estimated 1 to 2 percent of young people and rising to about one in 40 adults. About half are seriously impaired by the disorder, 35 percent moderately affected and 15 percent mildly affected.

It is not hard to see how the disorder can be so disruptive. A person with O.C.D. who is concerned that they may fail to lock the door, for example, may feel compelled to unlock and relock it over and over. Or they may become unduly stressed and anticipate disaster if a strict routine, like switching a light on and off 10 times, is not followed before leaving a room. Some people with O.C.D. are plagued by taboo thoughts about sex or religion or by a fear of harming themselves or others.

The comedian Howie Mandel, now 65, told MedPage Today in June that he has suffered from O.C.D. since childhood, but wasn’t officially diagnosed until many years later after spending most of his life “living in a nightmare” and struggling with an obsession about germs. He has been working to help counter the stigma of mental illness and increase public understanding of O.C.D. in hopes that greater awareness of the disorder will foster early recognition and treatment to avert its life-impairing effects.

How is O.C.D. treated?

“Until the mid-1980s, O.C.D. was considered untreatable,” said Caleb W. Lack, a professor of psychology at the University of Central Oklahoma. But now, he said, there are three evidence-based therapies that may be effective, even for the most severely afflicted: psychotherapy, pharmacology and a technique called transcranial magnetic stimulation , which sends magnetic pulses to specific areas of the brain.

Most patients are initially offered a form of cognitive behavioral therapy, called exposure and response prevention . Starting with something least likely to elicit anxiety — for example, showing a used tissue to people with an obsessive fear of contamination — patients are encouraged to resist a compulsive response, like repeated handwashing. Patients are taught to engage in “self-talk,” exploring the often irrational thoughts that are going through their heads, until their anxiety level declines.

When they see that no illness has resulted from viewing the tissue, the therapy can progress to a more provocative exposure, like touching the tissue, and so forth, until they overcome their unrealistic fear of contamination. For especially fearful patients, this therapeutic approach is often combined with a medication that counters depression or anxiety.

One silver lining of the pandemic is that it may have allowed more people to get treated remotely through online health services. “With telemedicine, we’re able to do very effective treatment for patients, no matter where they may live in relation to the therapist,” Dr. Lack said. “Without ever leaving central Oklahoma, I can see patients in 20 states. Patients don’t have to be within a 30-mile radius of the therapist. Telemedicine is a real game changer for people who won’t or can’t leave home.”

For highly impaired O.C.D. patients for whom nothing else has worked, the latest option is transcranial magnetic stimulation, or T.M.S., a noninvasive technique that stimulates nerve cells in the brain and helps to redirect neural circuits that are involved in obsessive thoughts and compulsions.

“It’s as if the brain is stuck in a rut, and T.M.S. helps the brain circuitry get on a different path,” Dr. Lack explained. As with exposure and response prevention, he said, T.M.S. uses provocative exposures, but combines them with magnetic stimulation to help the brain more effectively resist the urge to respond.

In a study of 167 severely affected O.C.D. patients at 22 clinical sites published in May, 58 percent remained significantly improved after an average of 20 sessions with T.M.S. The Food and Drug Administration has approved the technique for treating O.C.D., though many insurance companies are not yet offering coverage.

Where can I get help?

Bradley Riemann, a psychologist at Rogers Behavioral Health System in Oconomowoc, Wisc., said his organization, which has 20 locations in nine states, relies on treatment teams that include psychologists, psychiatrists, nurses and social workers to provide both outpatient and inpatient treatment for O.C.D. patients as young as age 6. Too often, Dr. Riemann said, parents inadvertently reinforce the problem by clearing a path so that their child can avoid their obsessive fear and resulting compulsive response. For example, they might routinely open doors for a child fearful of contamination.

The nonprofit International O.C.D. Foundation, based in Boston, can help patients and families find therapists and support groups for those struggling with the condition. A message can be left at 617-973-5801.

Jane Brody is the Personal Health columnist, a position she has held since 1976. She has written more than a dozen books including the best sellers “Jane Brody’s Nutrition Book” and “Jane Brody’s Good Food Book.” More about Jane E. Brody

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Real Event OCD: What Is it?

• Real Event OCD vs. Guilt/Shame

Obsessive-compulsive disorder (OCD) is a mental health condition in which a person experiences intrusive thoughts (obsessions) and engages in specific actions (compulsions) to relieve anxiety caused by the obsessions. The compulsions are often unrelated to the nature of the obsession, and the adverse consequences are almost always imagined and irrational.

Unlike most manifestations of OCD, real event OCD centers around an actual event that occurred in the past, instead of imagined expectations of future events. While everyone experiences guilt or regret, people with real event OCD become fixated on an experience that makes them question their character or morals, engaging in thoughts and actions that seek to reassure themselves.

Read on to learn more about real event OCD and its treatments.

Jamie Grill / Getty Images

What Is Real Event OCD?

People with real event OCD (also called real-life OCD) become fixated on actual events or past experiences that caused them to question their morality, making them feel as though they aren't a good person. They may replay the event over and over in their minds, analyzing all the details, and scrutinizing their role in it and any harm they may have caused through their actions.

They may worry about potential consequences of the event, such as losing a relationship with a loved one. They are also likely to take actions to reassure themselves, though this reassurance is short-lived.

The event can be something minor such as a rude remark to a customer service representative, something major like drinking and driving, or anything that makes them fear they are a bad person.

They may be focused on a recent event or something well in the past, such as an item they stole from a store as a child decades ago.

Real event OCD is typically made up of the following three components:

• Event : What really happened
• Obsession : Intrusive thoughts about what happened, often irrational or exaggerated
• Compulsions : Actions taken to try to gain temporary reassurance

Trauma-Related OCD

OCD symptoms may also be triggered by real-life experiences, like trauma . Traumatic experiences can include abuse, neglect, or other disruptions to family life.

Common Obsessions in Real Event OCD

Real event OCD obsessions can arise from anything that causes the person concern about their moral character, such as whether they are a good person, or potential future fallout stemming from the event.

These obsessions may include:

• Worrying they said or did something bigoted or offensive that has harmed a person they care about
• Believing that it is because of what they said or did that something bad happened
• Fearing consequences, such as punishment or being "canceled," or worrying about getting caught
• Believing their actions have caused harm or suffering to strangers
• Feeling they may have been hypocritical, inauthentic, unfair, and/or deceitful
• Worrying their thoughts or actions make them a bad person
• Worrying they have committed a crime
• Having repeated thoughts about confessing to a wrongdoing
• Having intense, overwhelming feelings of shame, guilt, or embarrassment about something they said or did
• Having repeated thoughts that they made a big mistake and now life will never be the same
• Having intrusive thoughts, images, and/or memories about an event or what happened afterward
• Wondering what would have happened if they hadn't said or done "X"

People with real event OCD tend to overestimate the importance of their actions. For example, they may ruminate regularly on a hurtful thing they said to a classmate in elementary school, worrying it caused them lasting harm, when their classmate doesn't remember the incident.

If they can't clearly remember every detail of the event, they are likely to assume something bad happened.

These obsessions cause anxiety that creates an urgent need to seek answers or reassurance.

Common Compulsions in Real Event OCD

A person with real event OCD will try to relieve the anxiety caused by their obsessions through compulsive actions. These might include:

• Seeking punishment for their actions
• Repeatedly going over past behaviors, looking for wrongdoings, and evaluating their actions
• Confessing or unnecessarily apologizing for their perceived wrongdoings (often after a long time has passed)
• Engaging in self-punishment by criticizing themselves and/or denying themselves from having positive emotions or experiences
• Seeking reassurance from friends and family either that they didn't do anything bad or that they aren't a bad person, sometimes using progressive hypothetical situations
• Doing online research on how to obtain forgiveness and/or how to forgive themselves
• Observing the person whom they believed they harmed to determine if their actions did negatively impact that person
• Repeatedly asking the wronged person for forgiveness
• Repeatedly confessing the previous negative things that were said or done
• Looking for ways to prove to themselves that they are a good person
• Engaging in excessive behaviors with the goal of becoming a better person
• Engaging in excessive good deeds to make amends for their wrongdoing
• Calling authority figures to inquire about potential consequences of past actions
• Repeatedly thinking about what they would have done differently if they had it to do over
• Reimagining the event the way they would have liked it to go
• Avoiding reminders, such as places, images, and people, that are related to the event

The relief brought on by these compulsions is usually temporary. The intrusive thoughts seep back in, and the cycle begins again.

How Is Real Event OCD Different From Guilt or Shame?

Everyone thinks back on past experiences and feels guilt or shame to some extent. However, people experiencing real event OCD have difficulty moving past these events.

Under usual circumstances, experiencing guilt can help people learn from their mistakes and do better in the future, whereas shame is less productive because it centers on a person's inherent value rather than specific actions that might lead to positive change.

However, people with real event OCD experience feelings of guilt and shame that are more intense and affect their ability to function well. It is more difficult for people with real event OCD to work through these feelings, reconcile them, and move on.

People with real event OCD have cognitive distortions (ways in which the mind warps or distorts information), such as:

• All-or-nothing thinking: This way of thinking focuses on the extremes and nothing in between. An example of all-or-nothing thinking is: "Because of what I did, I am dishonest."
• Magnification: Also called catastrophizing, a person perceives a relatively minor event in an exaggerated way. An example of magnification is: "I made a terrible mistake and can never forgive myself."
• Emotional reasoning: The person believes that the way they feel is evidence of something factual. An example of emotional reasoning is: "I feel afraid, so there must be danger present."
• Personalization: The person assumes responsibility and the blame for events that are beyond their control. An example of personalization is: "If I took better care of my parent, their illness wouldn't have gotten worse."

Treatment for Real Event OCD

First-line treatment for OCD is behavioral psychotherapy (talk therapy). Medication can be helpful for some people in combination with therapy.

Exposure and Response Prevention (ERP)

This evidence-based treatment involves exposing the person to their fears to help them learn to be less reactive to their triggers. ERP provides a safe place for challenging worries and working to increase the person's ability to tolerate uncertainty, discomfort, and doubt.

The goals of treatment are to reduce distress associated with triggering stimuli or situations and to decrease functional impairments in daily living. 

Examples of exposures during treatment may include:

• Listening to music or seeing images that remind them of the event
• Visiting the location where the event took place
• Writing out a narrative of the event
• Imagining all the ways that their words and/or actions negatively impacted the other person(s)
• Writing a worst-case-scenario story of the event and the negative consequences it created for the other person(s)
• Writing an uncertainty story describing how they will never know for sure how the other person(s) was impacted
• Creating a written confession of what happened or what they feared occurred
• Writing a story of how their behavior will have negative consequences, such as never being able to stop obsessing about the event; getting away with committing a crime; being rejected by others; or believing life will never be the same

In conjunction with exposure experiences, the treatment includes Response Prevention, which is designed to eliminate compulsions and deconstruct rituals. Examples include:

• Refraining from seeking reassurance or doing research on the internet, social media, etc.
• Actively seeking out enjoyment and positive experiences and not withholding pleasurable experiences
• Refraining from making apologies
• Refraining from repeatedly confessing the things that were said or done
• Refraining from avoiding reminders (places, images, people, etc.) that have to do with the event and allowing themselves to naturally come across these reminders.
• Interrupting mental reviewing compulsions by redirecting the mind to a more neutral topic or mental exercise
• Refraining from engaging in any other compulsive behaviors to attempt to gain more certainty about the event and its aftermath

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) involves identifying problematic thought and behavior patterns and gradually changing them into healthy ones.

The main form of CBT used for OCD is exposure and response prevention (ERP).

Under the guidance of a mental health professional, people with OCD are exposed to their fears at gradually increasing intensities. For a person with real event OCD, this might mean:

• Allowing intrusive thoughts to arise
• Exposing themselves to things, such as music or images, that make them think of the event or experience
• Writing stories or songs, or creating artwork about the event or the feared consequences of it
• Visiting the location of the event
• Engaging in actions that trigger the obsessive thoughts

During this exposure, the person is urged to resist doing any compulsions or actions to try to reduce the anxiety.

Over time and repeated exposures, the person builds an increased capacity to resist the compulsions and, ideally, the obsessions reduce.

Medication like antidepressants may be used to help manage symptoms, particularly along with therapy to strengthen the effectiveness of both treatments. Sometimes, other types of medications are used to increase the benefit of antidepressants.

Antidepressant medications that may be prescribed include:

Selective Serotonin Reuptake Inhibitors (SSRIs)

• Prozac (fluoxetine)
• Paxil (paroxetine)
• Celexa (citalopram)
• Luvox (fluvoxamine)
• Zoloft (sertraline)
• Lexapro (Escitalopram)

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

• Pristiq (desvenlafaxine)
• Effexor (venlafaxine)
• Cymbalta (duloxetine)

Tricyclic Antidepressant

• Anafranil (clomipramine)

Mindfulness

Mindfulness involves allowing thoughts to come and go without assigning them judgment.

Acceptance and commitment therapy (ACT) is a type of psychotherapy that integrates aspects of mindfulness that can be used to teach people with OCD to accept their intrusive thoughts, rather than reacting or responding to them.

One of the goals of ACT is to separate the intrusive thoughts from the thinker, allowing them to be seen as separate entities and taking actions based on a person's values, not their obsessions. This way, they can acknowledge the thought as an "OCD thought," not as a fact.

Thoughts can also be reframed. For example, instead of thinking, "I am a horrible person," they might think, "I feel bad that I did that." Labeling the action—not the person—allows room for positive change.

From there, the person can take actionable steps to make the situation better now and/or avoid repeating the behavior in the future. This helps to move past the situation in a healthy, productive way, instead of being caught in an obsessive-compulsive cycle.

OCD Support Groups

Support groups are not a substitute for professional treatments like therapy, but they can be very valuable. Talking to others who understand your experiences firsthand is a great way to foster community, share resources, and offer and receive support.

The International OCD Foundation offers useful information on how to find (or start) support groups.

Diet and Lifestyle Changes

OCD cannot be treated with lifestyle changes alone, but developing healthy habits is important for overall health and can be a great support for traditional treatments .

Healthy habits worth adopting include:

• Eating nutritious foods
• Moving your body regularly
• Getting enough quality sleep
• Practicing relaxation exercises, such as yoga, mindfulness, or meditation
• Avoiding/limiting tobacco, caffeine, and alcohol
• Following your treatment plan
• Engaging in activities you enjoy
• Fostering and maintaining positive relationships

Real event OCD is a form of OCD in which a person becomes consumed by thoughts and feelings of guilt about a real event that happened sometime in the past. These thoughts cause them to question their morality. Compulsive actions follow in an effort to manage the anxiety triggered by the obsessions.

Real event OCD is typically treated with medication and/or behavioral therapy. Healthy lifestyle habits and mindfulness may also be beneficial.

Frequently Asked Questions

Factors that may influence the development of OCD include:

• Brain structure and functioning
• Environmental factors, like childhood trauma or PANDAS syndrome

OCD has previously been categorized as an anxiety disorder . However, it is now classified as its own disorder by the American Psychiatric Association. Real event OCD is one way in which OCD can manifest, but it is not a separate condition in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the American Psychiatric Association's manual for diagnosing mental health disorders.

Real event OCD centers around actual memories of specific experiences. While no one's memories are 100% accurate, the memories involved with this form of OCD are based in reality.

False memory OCD is a kind of OCD in which a person has intrusive doubting thoughts around past events. For example, a person may worry they have hit someone with their car while driving sometime in the past, but are unable to determine if that event really happened or was fabricated by their mind.

California OCD and Anxiety Treatment Center. Dealing with real-event OCD .

Anxiety & Depression Association of America. The “reality” of real-life OCD .

Vidal-Ribas P, Stringaris A, Rück C, Serlachius E, Lichtenstein P, Mataix-Cols D. Are stressful life events causally related to the severity of obsessive-compulsive symptoms? A monozygotic twin difference study .  Eur Psychiatr . 2015;30(2):309-316. doi:10.1016/j.eurpsy.2014.11.008

Dykshoorn KL. Trauma-related obsessive-compulsive disorder: a review .  Health Psychol Behav Med . 2014;2(1):517-528. doi:10.1080/21642850.2014.905207

International OCD Foundation. Support groups .

National Institute of Mental Health. Obsessive-compulsive disorder .

Rosso G, Albert U, Asinari GF, Bogetto F, Maina G. Stressful life events and obsessive–compulsive disorder: clinical features and symptom dimensions . Psychiatry Research . 2012;197(3):259-264. doi:10.1016/j.psychres.2011.10.005

Substance Abuse and Mental Health Services Administration. DSM-IV to DSM-5 obsessive-compulsive disorder comparison .

By Heather Jones Jones is a freelance writer with a strong focus on health, parenting, disability, and feminism.

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Case Study: Obsessive-Compulsive Disorder

In a previous article we reviewed a range of treatments that are used to help clients suffering from obsessive-compulsive disorder (OCD). In this edition we showcase the case study of Darcy [fictional name], who worked with a psychologist to address the symptoms and history of her OCD.

Marian, a psychologist who specialised in anxiety disorders, closed the file and put it into the filing cabinet with a smile on her face. This time she had the satisfaction of filing it into the “Work Completed” files, for she had just today celebrated the final session with a very long-term client: Darcy Dawson. They’d come through a lot together, Darcy and Marian, during the twelve years of Darcy’s treatment for Obsessive-Compulsive Disorder, and they had had a particularly strong therapeutic alliance.

Marian reflected on the symptoms and history which had brought Darcy into her practice.

Obsessions at age nine

Now 37, Darcy reckoned that she had begun having obsessions around age nine, soon after her beloved grandma had died. Already grieving the loss of the person she was closest to in life, Darcy experienced further alienation – and resultant anxiety — when her father relocated the family from the small town in Victoria where they lived to Melbourne. Adjusting to big-city life wasn’t easy for someone as anxious as Darcy, and she soon found that she was obsessing. She had fears of being hit by a speeding car if she stepped off the kerb. She feared that the new friends she began to develop in Melbourne would be kidnapped by bad people. And she was terrified that, if she didn’t do an elaborate prayer routine at night, all manner of terrible things would befall her family.

The prayer routine, relatively simple at first, grew to gigantic proportions, containing many rules and restrictions. Darcy believed that she had to repeat each family member’s full name 15 times, say a sentence that asked for each person to be kept safe, promise God that she would improve herself, clap her hands 20 times for each person, kneel down and get up 5 times, and then put her hands into a prayer position while bowing. She “had” to do this routine at least 10 times each night, and if she made a mistake anywhere along the way, she had to start totally over again from the beginning, or else something bad would happen to her parents or little brother. Once she went flying to her mother’s side in the kitchen, tears streaming down her face, because she couldn’t get her “prayers” right. Darcy was certain that she was a huge disappointment to God and everybody.

Just like Granddad

Marian had asked Darcy if her parents were similar at all, and Darcy couldn’t think of many ways in which they were. Then she remembered something. “Ah,” she said, “my parents aren’t having these awful thoughts like me, but I remember my mum often telling me, ‘You’re just like your grandfather.’” Darcy’s grandfather had died when she was only five, so she didn’t have strong recollections of him, but there were two images that she always remembered about him: Grandfather standing by the kitchen sink in their farmhouse, washing his hands – always washing his hands. And if they decided to take a walk around the farm, he would take a seeming eternity to check that all the windows and doors were locked, even though they were on good terms with everyone within a ten-mile radius!

Obsessions and compulsions worsen through Uni

Marian had felt huge compassion for Darcy as she outlined the course that the disorder had taken. While the intrusive thoughts waxed during high-stress times and waned when Darcy felt relatively stable, there was nevertheless a general broadening of the obsessions – and resultant compulsion to do certain repetitive acts – throughout Darcy’s growing-up years. In high school, for instance, Darcy began to have an aversion to looking at any woman with a scoop-neck top on, going so far as to grab a glass and pretend to be holding it high up near her lips (as if to drink) if she had to talk to someone dressed in any but the most conservative top. In that way, she felt, she would be blocked from seeing what she should not see and thus sinning. Short skirts were also a problem, as Darcy feared that she was looking at people in inappropriate ways, and was offensive.

If anyone at a party crossed their legs while she was looking at them, Darcy assumed that they had done that because they were offended by her having glanced at them; she feared that they would think she was looking at their crotch area. She prayed constantly for forgiveness, but ended up ceasing hugs to family and friends because she felt like a hypocrite. Of course, not feeling that she could/should touch anyone made for huge social problems, and dating anyone became impossible: a huge punishment for a friendly extravert like Darcy. She petitioned God relentlessly, asking to be a better, less sinful person. It did not seem to help.

When Darcy began University, the experience was defined by a series of irrational obsessions. She would worry incessantly about having written something offensive on an email or an assignment. Walking around campus, she would pick up rubbish: papers that she had never seen before; she would worry that she might have written something on one of them. She feared that she would accidentally hurt one of her fellow students by something that she might do or say. By this time Darcy was repeating certain phrases over and over again to ward off disaster. She was amazed that she was getting through school at all (she often made straight A’s), because her rampant perfectionism caused her to take at least twice as long as other students to complete assignments, and she still wasn’t happy then. The anxiety and depression were overwhelming Darcy to the point where she recognised that she could barely function and something needed to change.

The Uni psychologist says, “You’re fine”

Marian shook her head in amazement as she recalled how Darcy’s first attempts to find out what was wrong with her had been fruitless; all the health professionals had completely missed the OCD! Upon first coming to Marian, Darcy had recounted how getting along to the University psychologist in her senior year was a “non-event”. He had asked a few questions, chatted to her about her schoolwork, told her she was basically fine, and then told her to go see a psychiatrist, who merely prescribed a sleeping pill. Darcy had taken this, as instructed, because the intrusive thoughts in her mind often did keep her from sleeping, but when she was awake she still had the thoughts and the horrible compulsion to perform the anxiety-alleviating acts: routines which now occupied several hours each day. Moreover, Darcy’s parents still didn’t believe that anything was wrong with her; they even found it funny that she was “quirky” like her grandfather.

Age 25: Treatment begins

Darcy was to graduate and spend another three years being held prisoner by her out-of-control mind before a chance meeting of her mother with a specialist in OCD at a conference. The specialist didn’t live in Melbourne, but – by incredible coincidence – he had a highly recommended colleague who did: Marian. Marian recalled with some fondness how Darcy had sat in her office during the first session, shedding tears of joy at being truly “seen”: both as a person and in her disorder. When Marian had issued the magical words, “Obsessive-Compulsive Disorder”, Darcy had been surprised – after all, her sense of OCD was people who continually washed their hands – but she also felt like she had just been given the key to her prison. Her treatment began soon after.

Marian worked intensively with Darcy at first, and then steadily. She helped Darcy get onto an even keel emotionally first by raising her serotonin levels (which had been quite low). Marian then began the laborious process of helping Darcy to change her habits of thinking: the assumptions that she made, the irrationalities that controlled her behaviour, and the intrusive obsessions that seemed to take over her life. Marian helped Darcy to see the importance of an exercise regimen, a good diet, and a stillness practice. Darcy joined an online support group, and Marian and Darcy enlisted the help of Darcy’s family and a few close friends. Partway through the therapy, Darcy was even able to come off the medications: a goal she had long sought, because she had married a “wonderful” man and they wanted to start a family.

At 37, Darcy is a happy and fulfilled person, with a solid marriage and an eight-year-old daughter. She believes that she worries about her “like a normal mother”, rather than in the obsessional way she used to pray in order to protect her family from imagined harm. She still petitions God, as she is active in her church, but now the petitions are free of the superstitious routines she used to perform, and she is quick to be thankful for her many blessings.

Unwanted thoughts still come to her, but now she has tools to focus elsewhere, and when the intrusive thoughts come, Darcy knows how to keep them from causing her to repeat irrational acts in a compulsive way. She knows that she will probably always be managing her disorder, as there is no cure for OCD. But the difference now is that she controls it, rather than having it control her. As far as Darcy is concerned, Marian gave her back her life.

Marian smiled again as she recalled Darcy’s journey and her original fear of being a “disappointment to God and everyone”. Indeed, Marian felt blessed to have had Darcy as a client.

This article is an extract of the upcoming Mental Health Academy “OCD and OCPD Case Studies” CPD course. Click here for a full list of currently available MHA continuing professional development courses.

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I have OCD. Some cognitive behavioral therapy techniques were totally wrong for me

Many practitioners consider CBT the gold standard of therapy, but does it work for everyone?

T he first time I learned about cognitive behavioral therapy (CBT), I felt the pleasure of recognition and of superiority. I was in high school, and it would be years before I visited a therapist of any kind, but from what I gathered online, CBT consisted of what I was already doing.

The modality grew from a core belief that irrational thoughts are responsible for emotional suffering, according to Rachael Rosner, a historian writing a biography of Aaron Beck, the father of CBT. It followed that changing these thoughts could alleviate the distress.

Perhaps you’re afraid that your headache is a sign of a brain tumor. The CBT “ thought record ” technique might advise you to gather the facts for and against this fear. Is there a family history of brain tumors? Could the headache be caused by dehydration? Then, you reframe it into a more realistic, and presumably less panicked, position.

This back-and-forth volley already described my inner monologue. Years later, I chose for my first therapist one who practiced an old-school form of CBT that reinforced these habits.

It was easy to find such a therapist. Though exact statistics are scarce, CBT is a common modality. Many practitioners consider it the gold standard of psychotherapy and use it for conditions including anxiety and depression. By 2002, the Washington Post was claiming : “For better or worse, cognitive therapy is fast becoming what people mean when they say they are ‘getting therapy’.”

Its concepts “are very mainstream now”, says Sahanika Ratnayake, a philosopher of medicine and psychiatry. “You hear people talking about ‘cognitive distortions’ and ‘reframing your thoughts’ and this idea that how you think about something changes how you feel about it.”

Yet despite being fluent in these techniques, I remained trapped in rumination. Knowing all the cognitive distortions – types of negative bias or irrational thinking – didn’t lessen the worry. No matter how much evidence I gathered to prove that a worry was unlikely, I couldn’t forget that improbable things do happen. People were struck by lightning, planes did crash, headaches did turn out to be tumors. Eventually, I switched to psychodynamic therapy (more focused on feelings, more helpful for me) but continued my inner debate tournament.

Then, in my 30s, I was diagnosed with obsessive compulsive disorder (OCD), a condition marked by intrusive thoughts and physical or mental compulsions to get rid of the thoughts. This delay wasn’t uncommon: diagnosing OCD can take up to 14 to 17 years , in part because it can be hard to differentiate from other disorders such as anxiety. During that time, those thought-challenging techniques can backfire. They did for me.

T he story of modern CBT is, in part, the story of being in the right place at the right time: the US in the 1980s. After the Diagnostic and Statistical Manual of Disorders III, the handbook for diagnosing mental disorders, came out in 1980, the National Institute of Mental Health started requiring that researchers conduct randomized controlled trials for therapy if they wanted funding. By then, Rosner says, Beck had already created a manual for CBT so that it could be standardized and studied in this way. This meant CBT therapists could adapt quickly to the new rules, and the techniques took off.

As insurance companies warmed to CBT, therapists developing new modalities liked to associate with CBT too, partly so these forms could also be covered by insurance, according to Ratnayake. Today, CBT is a broad label that can include mindfulness skills and distress tolerance skills, for instance.

Still, it’s the original ideas around adapting irrational thoughts – the “cognitive” part of CBT – that seem to have trickled most into the mainstream. Behavioral and exposure-based CBT techniques are effective, but therapists can be less likely to use these methods , says Dean McKay, a psychology professor at Fordham University. Articles mentioning CBT tend to emphasize the “distorted thinking” aspect, as do most free worksheets – all contributing to the mistaken idea that CBT is primarily about being rational.

Cognitive techniques work for many. But “the typical OCD sufferer already knows the evidence”, adds McKay, who has researched the potential harms of CBT-type interventions . For them, evidence-gathering becomes just “another form of reassurance”. Reassurance (“of course you won’t die after eating food off the ground”) helps people with OCD feel better in the short term but reinforces the fear long term (“what if I’m the freak exception who will die?”), so they end up needing more and more comfort.

Katie O’Dunne, a minister and interfaith chaplain with OCD, experienced a compulsive cycle of reassurance related to intrusive fears about hurting others. Her therapist asked O’Dunne to list all the great things she’d done and remember that she was a nice person. It worked, briefly. Then her brain would start circling the same questions again: “It made the intrusive thoughts stronger because they would come back and find new ways to poke holes in the logic.”

O ddly enough, the first-line treatment for OCD is a form of CBT – just not the type that many would associate with the label. The difference in approach is clear in these practice phrases from a guidebook for people with OCD : There is no way I can guarantee I won’t stab my husband. Despite my best efforts, my neglect might cause a fire at work. I can’t be sure that my spouse will remain faithful to me.

This type of treatment, called exposure and response prevention (ERP), doesn’t try to dispute thoughts. It encourages patients to expose themselves to fears, either in a real or imagined situation , accept that it could happen – and not do anything to relieve the fear. Instead of reaching for the reams of evidence that you won’t stab your husband, live with the possibility that you might.

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To me, this approach was more helpful. As someone who would obsess over the 0.0001% chance I could be struck by lightning , acknowledging that chance feels like facing reality.

When I stopped trying to think rationally, my mind felt freed. I no longer needed to constantly remind myself to stop catastrophizing. I had permission to stop sifting through piles of research in a search for certainty. Instead, I started practicing ERP whenever the fears began. I can never be 100% certain that I won’t develop my mother’s disease , I would think, despite “knowing” that her illness was due (almost certainly) to bad luck.

At first, I flinched at the idea and pressure grew in my chest. But with time and repetition, my mind became less prone to these looping thoughts. And I began thinking about how this approach could help beyond OCD.

O ’Dunne, the chaplain, leads online groups for people navigating faith and OCD, but the community has started to include those without the disorder. “A lot of people who have navigated religious trauma or spiritual abuse or really rigid spiritual communities have been told for such a long time that they have to have certainty,” she says. “It’s been such a harmful dynamic.” To her, ERP isn’t just a treatment but rather “a beautiful, healthy lifestyle of uncertainty”.

In fact, “ intolerance of uncertainty ” is correlated with many conditions, including generalized anxiety, OCD, social anxiety and eating disorders, according to Mark Freeston , a psychologist at Newcastle University who has studied the concept since the 1990s. Instead of focusing on cognitive distortions, Freeston and collaborators help patients accept physical signals of uncertainty.

For example, patients play a children’s game where they pass around a spring-loaded toy. Because people know the outcome – the toy pops up – but not when it’ll happen, they learn to identify “temporal uncertainty” and realize that the feeling doesn’t mean a situation is dangerous. They can experience uncertainty and still be OK. In a study of group treatment that Freeston and his collaborators plan to submit for publication, they found that “making friends with uncertainty” helps decrease anxiety, even if the treatment never addresses a specific worry.

In the end, it’s not that challenging one’s thoughts doesn’t work (it can) or that behavioral strategies work for everyone (they won’t). Some people respond to evidence; they feel its rational force and are comforted. Others may prefer art therapy or internal family systems , a protocol that asks clients to work with different “parts” of their psyche. Approaches that involve analyzing the past can bring insight for some; for others, including people with OCD, focusing on the origin of intrusive thoughts can distract from getting better.

There are many reasons we might suffer, and no approach works for everyone – but for myself and many, with and without OCD, the cognitive form of CBT was the one most often held up to be obviously and generally helpful. For me, this led to simplistic and misguided understandings, both of CBT itself and of what I needed. I loved CBT’s cognitive strategies because the self-questioning came naturally, but for precisely that reason, I needed a treatment that did the opposite. I just wish it hadn’t taken so long.

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Case Study: Cho

Possible treatment considerations for Cho may include CBT or eye movement desensitization and reprocessing (EMDR). This could also be coupled with pharmaceutical treatment, such as anti-anxiety medication or anti-depressants to help alleviate symptoms. Cho will need a trauma therapist who is experienced in working with adolescents. Other treatment that may be helpful is starting family therapy as well to ensure everyone is learning to cope with the trauma and work together through the painful experience.

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To read more about the ongoing issues of PTSD in violent-prone communities, read this article about a mother and her seven-year-old with PTSD .

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If you were a licensed counselor working in a community that experienced a high rate of violent crimes, how might you treat the patients that sought therapeutic help? What might be some of the challenges in assisting them?

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Case Study of a Middle-Aged Woman’s OCD Treatment Using CBT and ERP Technique

• Clinical Medical Reviews and Reports

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Case report, case formulation, intervention, preparation phase of erp, middle phase of erp, steps of hierarchy, booster sessions, quick links.

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Research Article | DOI: https://doi.org/10.31579/2690-8794/102

• Deepshikha Paliwal 1*
• Anamika Rawlani 2

1 M.Sc. Clinical Psychology, Dev Sanskriti University, Ranchi, India. 2 M.Phil Clinical Psychology, RINPAS Ranchi, India.

*Corresponding Author: Deepshikha Paliwal, M.Sc. Clinical Psychology, Dev Sanskriti University, Ranchi, India.

Citation: Deepshikha Paliwal and Anamika Rawlani (2022) Case Study of a Middle-Aged Woman’s OCD Treatment Using CBT and ERP Technique. Clinical Medical Reviews and Reports 4(3): DOI: 10.31579/2690-8794/102

Copyright: © 2022, Deepshikha Paliwal, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 01 September 2021 | Accepted: 04 December 2021 | Published: 10 January 2022

Keywords: OCD; CBT; ERP; salkovskis’s model

Introduction : This is a case report of a middle-aged woman, who was experiencing “obsessive” thoughts related to the “Bindi” (decorative piece wear by women on the forehead) and cleaning “compulsions”. Present case report discusses the patient’s assessment, case formulation, treatment plan and the effectiveness of the CBT and ERP sessions in reducing OCD symptoms.

Methodology: The patient was treated with Cognitive Behavior Therapy (CBT) along with Exposure Response Prevention (ERP) technique. The assessment of the case was done with the Y-BOCS rating scale, Beck’s Depression Inventory, Obsessive Beliefs Questionnaire, and Behavior Analysis Performa which suggested the higher severity level of the patient’s symptoms. Parallel to the assessment sessions, detailed case history related to the onset of the problem, difficulties faced because of the disorder, childhood incidences, family chart, marital issues, and medical history were discussed with the patient. Based on the reported details, the case was formulated according to the Salkovoskis inflated sense of responsibility model.  After the case formulation, the treatment plan was designed which involved ERP sessions and restructuring of the cognitive distortions (beliefs, thoughts, and attitude). 

Results: After the completion of the twenty-five therapy sessions, the patient reported improvement in the coping of anxiety-provoking thoughts and reduced level of the washing compulsions. The effects of the therapy were checked and found maintained up to two months follow up.

Conclusion: CBT and ERP technique is an effective treatment in reducing obsessive and compulsive symptoms of the patient. 

Have you ever felt like a sudden urge to hurt somebody? What if such urges continuously appear in your head? What would you do to stop these urges? Would you be able to continue your day to day life normally with such urges?  Clinical Psychologists studied the repetitive occurrence of unwelcoming thoughts, urges, doubts, and images which create anxiety. They gave it the term “Obsessions”. These obsessions are dreadful, frightening, and intolerable to the extent that they might hinder the natural flow of one’s personal, professional, and social life. The person who suffers from such anxiety-provoking thoughts tries to deal with the distress caused by such ‘obsessions’ by adopting some behavior or activity which temporarily relieve them from the anxiety and the feared consequences. This behavior could be anything like washing hands, cleaning, repeatedly checking the door, or repeating some phrases in the head. Psychologists called such repetitive behaviors or activities as “Compulsions”. According to APA (1994), if the presence of obsessions and/or compulsions is time-consuming (more than an hour a day), cause major distress, and impair work, social, or other important functions then the person will be diagnosed with Obsessive-Compulsive Disorder (OCD). Recent epidemiological studies suggest that OCD affects between 1.9 to 2.5% of the world population at some point in their lives, creating great difficulties on a professional, academic and social level (DSM-IV-TR, 2001). OCD affects all cultural and ethnic groups and, unlike many related disorders, males and females are equally affected by this disorder (Rasmussen & Eisen, 1992). OCD is one of the most incapacitating of anxiety disorders having been rated as a leading cause of disability by the World Health Organization (1996).  The major cause of OCD is still unknown; there could be some genetic components responsible for it (DSM-5). Child abuse or any stress-inducing event could be the risk factor involved in the history of OCD patients. The severity of the symptoms related to obsessions and compulsions provides the basis of the diagnosis in OCD which rules out any other drug-related or medical causes. Clinical Psychologists use rating scales like Y-BOCS (Fenske & Schwenk, 2009), self-reports, and Behavior Analysis Performa to assess the severity level of the symptoms. Based on the severity, the treatment plan is designed. Treatment of OCD involves psychotherapy and antidepressants. Psychotherapy such as Cognitive Behavior Therapy (CBT) is an effective psycho-social treatment of OCD (Beck, 2011). In CBT, a “problem-focused” approach is used to treat the diagnosed psychological disorder by challenging and changing core beliefs, negative automatic thoughts, and cognitive distortions of the patient. CBT involves Exposure Response Prevention (ERP) as a technique to treat OCD in which the patient is exposed to the cause of the problem and not allowed to repeat the ritual behavior (Grant, 2014).  ERP has promising results with 63% of OCD patients showing favorable responses after following the therapy sessions (Stanley & Turner, 1995). 

This is a case of a 31 years old woman, who belongs to a middle socio-economic background, currently living with her in-laws, husband, and daughter. The patient was experiencing obsessive thoughts related to the contamination spread by ‘bindi’ along with the compulsive behavior of washing and cleaning from the last five years. The patient reported that she always tried to check the contact of ‘Bindi’ with anything because that contact makes her incapacitate to control the situation. She took two and three hours (on daily basis) in washing and cleaning her home, scrubbing her daughter, cleaning the daughter’s school bag after returning from school, husband’s bag, and other usable items, so that she can stop the contamination from spreading everywhere. The patient has a history of facing interpersonal issues with family members since her childhood. Her father was alcohol dependent and the mother was the patient of depression. The financial condition of the family was not good. When the patient was 17 years old, her father died due to kidney failure, and her mother got hospitalized because of depression. From a very young age, the patient had to bear the responsibility of the family by taking tuitions. At first, she developed the fear of contamination at the age of 19, when she was in her graduation’s first year, for that she was taken to the Psychiatrist. She responded well to the medicines and stopped showing all the symptoms. At the age of 25, when the patient got pregnant she again developed the fear of contamination, which made her husband and in-laws uncomfortable and family disputes began. Her husband took her to the psychiatrist who referred her for the psychotherapy but she didn’t attend the psychotherapy sessions properly and continuously lived with the obsessions and compulsions up to the present referral where the patient was assessed with Y-BOCS rating scale, BDI, EBQ, and Behavioral Analysis Performa. Based on the assessment, she was diagnosed with OCD having symptoms of obsessions related to the contamination by ‘Bindi’ and washing compulsions. Detailed case history related to the onset of the problem, childhood incidences, family history, marital history, medical history, and other relevant information were also collected. The case was formulated according to Salkovoskis’s inflated sense of responsibility model as the patient’s reported details were signifying the negative interpretations of her responsibility for self and others. After the case formulation, the treatment plan was designed which involved sessions of ERP technique along with the alteration of cognitive distortions (ideas, beliefs, and attitudes) through the cognitive restructuring method of CBT. 

1. Yale-Brown Obsessive-Compulsive Scale (YBOCS): 

In cognitive-behavioral studies, Y-BOCS is used to rate the symptoms of OCD. This scale was designed by Goodman et al. (1989) to know the baseline and the recovery rate of the ‘severity of obsessions’, ‘severity of compulsions’ and ‘resistance to symptoms’. This is a five-point Likert scale that clinicians administer through a semi-structured interview in which a higher score indicates higher disturbances. The excellent psychometric properties of this scale quantify the severity of the obsessions and compulsions as well as provide valuable qualitative information which makes it very useful for both diagnosis of the OCD and the designing of its treatment plan. 

2. Beck Anxiety Inventory (BAI):

Aaron T. Beck (1988) developed BAI as a four-point Likert scale which consists of 21 items of ‘0 to 3’ scores on each item (Higher score means higher anxiety). If the Patient’s scores are from 0 to 7 then interpret as ‘minimal anxiety’, 8 to 15 as ‘mild anxiety’, 16 to 25 as ‘moderate anxiety’, and 30 to 63 as ‘severe anxiety’.  BAI assesses common cognitive and somatic symptoms of anxiety disorder and is considered effective in discriminating between the person with or without an anxiety disorder. This scale provides valuable clinical information but is not used by clinicians for diagnostic purposes. 

3. Obsessive Belief Questionnaire (OBQ):

OBQ is used to assess the beliefs and appraisals of OCD patients which are critical to their pathogenesis of obsessions (OCCWG, 1997, 2001). This scale consists of 87 belief statements within six subscales which represent key belief domains of OCD. The first subscale is ‘Control of thoughts’ (14 items), the second is ‘importance of thoughts’ (14 items), third is, responsibility (16 items), fourth is ‘intolerance of uncertainty’ (13 items), the fifth is an overestimation of threat (14 items), and sixth is ‘perfectionism’ (16 items). Response on this measure is the general level of agreement of the respondents with the items on a 7 point rating scale that ranges from (-3) “disagree very much” to (+3) “agree very much”. On the respective items summing of the scores is done to calculate the subscale scores.

4. Behavior Analysis Performa

This study used ‘Behavior Analysis Performa’ to do the functional analysis of the patient’s behavior. This Performa collects the details of the patient’s behavioral excess, deficits, and assets, his or her motivational factors behind maintaining and reinforcing ill behaviors, as well as, the medical, cultural, and social factors which contributed to the development of the illness. 

Based on the reported details and the assessment, the case was formulated according to the Salkovoskis model (1985). This model suggests that the patient’s main negative interpretation revolves around the idea that his or her actions might have harmful outcomes for self or others. This interpretation of responsibility increases selective attention and maintains negative beliefs (Salkovskis, 1987). Here, in this case, the patient had to face the disturbing family environment which significantly has a role in the formation of maladaptive schemas related to her negative view of self, the world, and the future. The patient’s beliefs assessment reports signified that her major dysfunctional assumptions were ‘if harm is very unlikely, I should try to prevent it at any cost’ and ‘if I don’t act when I foresee danger then I am to blame for any consequences’. Intrusive thought for her was that ‘bindi contaminates dirt’ and neutralizing action for this intrusive thought was ‘washing and cleaning things’. She paid her keen attention to the thought that ‘I should not be get touched with bindi’ and misinterpreted and over signified it by avoiding bindi and preventing the contamination. Her safety behavior included avoiding going out, (especially beauty parlors and cosmetic shops), and getting touched with anyone on roads and market places. The result of such avoidance was tiredness, anxiousness, aggressiveness, and distressed mood state. The graphical representation of the case formulation is shown in Appendix 1 at the end of this paper.

After the case formulation, the treatment plan was designed. The patient had dysfunctional assumptions related to her responsibility for self and others. She had obsessions related to the contamination spread by ‘Bindi’ associated with washing and cleaning compulsions. As she was taken by her husband for the therapy, so it was important to socialize her and her family with the OCD to develop insight for the disorder. After socializing them with OCD, they were taught the basic structure of the cognitive behavior model that how patient’s thoughts, emotions, physical sensations, and behavior all are interrelated and affect each other in a vicious circle. 

In the preparatory phase, the patient was introduced with the ERP technique, how does it work and how much her cooperation and will power are required for the success of this technique. After introducing the ERP technique to her, behavioral analysis was done with the patient by using a down-arrow method to make the list of the situations she uses as safety strategies and maintains her negative beliefs.

In the next session, the patient was told to imagine her exposure with different situations which she avoids and asked her to rate the level of anxiety in all the situations on a scale of 1 to 10. After this imaginary exposure, a hierarchy was made from the least anxiety-provoking event to the high anxiety-provoking event. Here is the list of different situations which the patient rated based on the level of anxiety:

In this phase, the patient was gradually exposed with the least anxiety-provoking situation to the highest-anxiety provoking situation. The patient’s husband worked as a co-therapist and accompanied her in all the situations and observed her anxiety levels and other behaviors. The patient was asked to rate her anxiety level on a scale of 1 to 10 after every exposure.

• In the first step of exposure, patient was instructed to go out with the husband in the market area where ‘Bindi’ was hanging on the walls , she was instructed to watch them from some distance and observe her level of anxiety varying with time . She was strictly instructed not to avoid the situation and to face the anxiety levels without skipping. In the next session, she was asked what she exactly felt when she was watching the bindi packets, she replied that at first sight of bindi she felt disgusted and wanted to go away but she gave self instructions to her that these are very far and cannot contaminate her so she kept sitting there and with time her anxiety level also came down.   
• In the second step of the hierarchy she was instructed for sitting at a distance from the cosmetics shop and observe the ladies entering and purchasing bindi there , her husband was told to work as a co-therapist and checks the anxiety levels and reactions of his wife during the exposure. In the next session, she was again asked for the thoughts and levels of anxiety during the observation, husband reported that at first she showed some anger and was looking very anxious while observing the ladies with bindi but when he reminded her about the nature of therapy, she managed to sit there and sometime later became relaxed.   
• In the third step of the hierarchy patient was instructed to enter into the cosmetic shop and remain stand there for a short while without purchasing anything and to face the levels of anxiety varying with time. In the session, she was asked to report the anxiety level. She reported that just when she entered the shop she was trying to not get touched with anything and felt like she would lose her control and became very anxious but with self instructions she managed herself to stand there after sometime anxiety level came down and she felt little relaxed.   
• In the fourth step, the patient was instructed to enter into the cosmetic shop and to purchase some common items other than ‘Bindi’ . In the next session, husband reported that she was attentively noticing the shopkeeper’s movements. Though, she purchased some ribbons but denied to touch them and asked him to put them in his bag and told him to give only the fixed amount of ribbon’s cost to the shopkeeper so that exchange could not be needed from shopkeeper’s contaminated hands. The husband also observed that during the whole exposure, the patient was looking very distressed and anxious and was involved in safety strategies and managed to calm down only when he reminded her about the process of therapy. The patient was then asked to report her anxiety level in this step of exposure.  
• In the fifth step, patient was instructed to go into the market and purchase a packet of small colorful bindi and face the anxiety levels . In the next session, she was asked to express the anxiety and rate it on a scale of 1 to 10. The patient reported that when she was purchasing the bindi, she felt dreadful and thought that she would take bath after returning home. Somehow, she purchased the packet and gave it to the husband to put it in his bag. After returning home, she got involved in her daughter’s work but thoughts of washing and bathing were going on in her mind. Later on, she could not get the time for bathing and she instructed herself to bath in the morning, after this thought she felt very relaxed and had this feeling of winning over her obsessions.   
• In the sixth step, patient was instructed to purchase some colorful bindi packets and try to keep them with herself and strictly prevent herself from hand-washing for one hour. In the next session, she reported that this time she was not that anxious while purchasing bindi packets but after putting them in her bags she was trying to avoid getting touched with her daughter and mother in law because her mother in law would enter into the kitchen and contaminate everything. Meanwhile, her daughter ran towards her and hugged her. Immediately, she became very restless and angry with the daughter and thought about to wash her. However, she felt incapacitated as her daughter ran everywhere in the house and touched everything. She got anxious but managed this thought of contamination and decided to not wash anything. After this, she felt relaxed.   
• In the seventh step of the hierarchy, the patient was instructed to apply a small bindi on her forehead and restricted to not wash her hands for at least four hours . In the next session, she reported that she applied the bindi and her husband and her mother-in-law were feeling very happy but she felt anxious and closed her fist for not touching anything till hand-washing. After some time, in other household works, she forgot about it but suddenly when she realized that she had applied bindi, she immediately washed her hands but even then kept wearing it for the whole day.   
• In the eighth step, the patient was instructed to apply red color velvet medium size Bindi and prevent hand washing for minimum of two hours . In the next session, she reported that now her level of anxiety has fallen down and now she feels less anxious after applying bindi and managed to not wash her hands for two hours without any much restlessness.   
• In the ninth step of the hierarchy, the patient was instructed to apply red color velvet medium size Bindi and prevent hand washing for minimum of four hours and try to make herself normal and gradually start touching things in these hours. In the next session, she reported that now she feels capable to face her feelings of disgust with bindi and manages to make her mind for not washing things after getting touched with the bindi. Though some thoughts of contamination keep coming in between but she immediately reminds herself that ‘Bindi’ can’t contaminate anything.  
• In the tenth step of hierarchy, the patient was instructed to apply bindi on her forehead and keep some of them in her bag preventing washing her hands for maximum hours possible. In the next session, she reported that now she feels more capable to conquer over her thoughts of contamination and more determined to not washing and cleaning after such obsessions.

With each ERP session, the patient came to realize that the nature of anxiety is that it goes up with the triggering event but with the passage of time, automatically comes down. She also developed the insight that she had fear from the thoughts of contamination and with its associated anxiety more than ‘Bindi’ itself. 

After the ERP sessions, the patient was given two booster sessions in which she was taught the ways to deal with the anxiety after the termination of therapy in her day to day life situations. In those sessions, she was asked to imagine her home, her room, and herself with Bindi on her forehead and doing household chores like cooking, cleaning the things, etc. When the patient was asked to express herself during the imagination, she reported that she is feeling more confident now to stick on her thought that bindi can’t contaminate, it’s her idea and there is no use of washing hands and other things because of the fear of contamination. Her husband and mother-in-law were also instructed to remind her again and again about the things she learned during the therapy sessions. After the declaration of the patient that she is feeling better now and ready to face the anxiety on her own, therapy sessions were terminated.

One month later, the patient was contacted for the follow-up and asked about her coping with the anxiety through telephonic conversation. She reported that thoughts of contamination came in her mind but she is in better condition than previous after taking the ERP sessions.

After two months, the patient came for the session again with the complaints that sometimes she became weak and washed her hands with the thought of contamination. After washing, she repented on her behavior which lowers down her confidence in conquering over the illness. Then she was instructed that washing hands strengthens the thought of contamination so she should avoid it as much as possible but this doesn’t mean that she has not gained anything with the therapy, she was reminded about her previous condition that how much it was unbearable for her to even think about the bindi but now she is applying it on her forehead which shows that only the traces of the illness left, most of it is already recovered. In this way, the patient became relaxed and felt more determined to continue with the learnings during the sessions.

After the termination of the therapy sessions, the patient’s obsessive and compulsive symptoms were found reduced on the Y-BOCS symptom checklist:

With the graded exposure sessions, her anxiety level also came down from the rating of 10 in the beginning sessions to the rating of 4 in the endings sessions on a scale of 1 to 10.

The patient’s BAI score was also fallen down from pre-intervention- 36 (Extreme level of anxiety) to post intervention- 13 (mild level of anxiety) which suggests 36% reduction in the anxiety level of the patient.

Previous research findings considered CBT as the most promising treatment of OCD (Stanley & Turner, 1995; Foa et al, 1999). CBT emphasizes the integration of cognitive-behavioral strategies like discussion techniques (Guided Discovery) and behavioral experiments (ERP) to formulate the problem and direct the treatment. Therapists try to identify the key distorted beliefs along with patients and allow them to test their beliefs which develop and maintain compulsive behaviors. This case identified the contamination with ‘Bindi’ as the pathological belief which was maintaining the compulsive behaviors of washing and cleaning. The cognitive hypothesis of Salkovoskis (1985) proposed that the origin of obsessional thinking lies in normal intrusive ideas, images, thoughts, and impulses which a person finds unacceptable, upsetting, or unpleasant. The occurrence and content of these intrusive cognitions are negatively interpreted as an indication that the person may be ‘responsible for harm’ or ‘prevent the harm’. Such an interpretation is likely followed by emotional reactions such as anxiety or depression. These emotional reactions lead to discomfort and neutralizing (Compulsive) behaviors like washing, cleaning, checking, avoidance of situations related to the obsessive thought, seeking reassurance, and attempts to exclude these thoughts from the mind. The present case supported this hypothesis of Salkovoskis’s model as intrusive thought of the patient was contamination spread by ‘Bindi’ which negatively interpreted as ‘I can avoid the likely harms by avoiding the contamination spread by Bindi’, such negative interpretation was raising her anxiety levels, making her attentive selective towards the ‘Bindi’, maintaining her compulsive acts and complying her to adopt the safety strategies.

Rachman (1983) predicted that behavioral experiments, in which the patient is exposed to the feared object, these intrusive thoughts are challenged by changing the pattern of thinking and behaving. Hodgson & Rachman (1972) initiated the series of clinical studies on patients with contamination and predicted that immediate washing reduces the anxiety. In one of their experimental study, they noted a similar degree of anxiety reduction when the patient was asked not to perform a compulsive act for one hour.  They termed this phenomenon as ‘spontaneous decay’ which was established as the basis of ERP. Also, Foa & Kozak (1986) proposed that exposure techniques activate the network of cognitive fear and patients get new experience which is different from the existing pathological beliefs. This case confirmed this hypothesis as the patient initially thought that her exposure with ‘Bindi’ might cause some uncertain consequence with her but prolonged exposures provided her new experience that she could manage with her fear and anxiety which resulted in the improved coping with obsessional beliefs about contamination and urge to wash and clean. Her improved coping is evident in the statistically significant reduction of her scores on the standard measures like the Y-BOCS symptom checklist, BAI, and OBQ. 

The results of this case study add on the value of CBT (that involves ERP technique) in the treatment of obsessive thinking related to the ‘fear of contamination’ and compulsive behavior of ‘washing and cleaning’. However, there is a need for more such case studies with more precision and effective treatment designs to provide valuable information related to the nature of OCD and its treatment.

In this case of OCD, patient’s symptoms were reduced to a manageable level and found maintained for two months which provides an evidence of the effectiveness of CBT and ERP technique in the treatment of OCD.

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A CLINICAL CASE STUDY OF INDIVIDUAL WITH OBSESSIVE COMPULSIVE DISORDER (OCD)

I ndian j ournal of h ealth s ocial w ork.

Prashant Srivastava1, Kavya Ahu2, Vani Narula3

1Psychiatric Social Worker, Dept. of Psychiatry, Kalpana Chawla Government Medical College and Hospital, Karnal, Haryana, 2M.Sc Clinical Psychology, Amity University, Gurugram, Haryana. 3Associate Professor, Dept. of Social Work, Jamia Millia Islamia, New Delhi. Correspondence: Kavya Ahu, e mail: [email protected]

It’s a matter of great pride for me that All India Association of Medical Social Work Professionals is launching first issue of “Indian Journal of Health Social Work” on the auspicious occasion of 6th Annual National Conference of AIAMSWP, 2019.

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