Jon Hershfield's Blog
April 8, 2020
Be Grateful! Be Productive! Or Maybe Just Be Good to Yourself?
In times of great stress, we are often told to remember to be grateful for what we have and to be as productive as we can be. OK, I actually can’t think of any times like these, but I am seeing a lot of people on the internet tell me to be grateful for what I have and to be productive during social distancing. These concepts can be extremely helpful, but they can also backfire, especially when the end of the stress remains unknown. I can be an Olympic gold medalist in gratitude and productivity for a week, maybe two, but I need a deadline to keep me going strong.
For the chronically stressed (which most of us are now in one form or another) with no deadline in sight, intensely focusing on what you’re grateful for in your life can bring on powerful feelings of guilt for complaining at all. If I have loved ones who care for me, a comfortable living situation, the freedom to listen to great music and enjoy great movies, and I’m still feeling unhappy, then I’m just a terrible ingrate! Similarly, while being productive, task-oriented, and creative certainly reduces rumination and increases satisfaction in life, the pressure to pump out new accomplishments in the face of a global pandemic can be exhausting or panic-inducing. I propose we take these otherwise good ideas and modify them to reduce our suffering during this absurd and terrifying moment in history.
Be grateful! (for yourself)
It should go without saying that people working in hospitals and other essential fields right now deserve a mountain of gratitude. And one would hope that being home has opened many of us up to recognize how grateful we are for any comforts we have and any loved ones we are near to. A little time off may have increased your gratitude for your favorite foods or entertainment as well. It’s good to notice what contributes to your happiness. But it’s also good to notice that you noticed it. This is one of the key skills in mindfulness meditation, to notice the noticing itself as an object of attention in consciousness. What’s that he said? Just a fancy way of saying you’re pretty cool for recognizing what’s good in your life. Not only that, what you’ve recognized is something that’s pretty cool about you. I have some admittedly peculiar tastes in music and movies, but when I find a sound or a scene that brings me joy, I also try to find joy in the finding of it. It was my ears and my eyes that picked that up, and me who embraced it. That kind of gratitude positions you to notice the good things in life, the things that have not changed for the worse due to COVID-19, and you can be one of those things.
Practice being grateful for any time you treat yourself with kindness and patience in these stressful times. Practice being grateful for how you chose to handle a situation that actually worked out for you. Practice being grateful for who and how you are. No, you’re not perfect. Maybe you have a lot of problems. But there are things about you that you wouldn’t trade for anything. You can even try writing a modified gratitude list, an “I’m grateful for me” list. For example, I’m grateful that I chose to do something nice for myself today, I’m grateful that I still have my sense of humor, I’m grateful that I responded to an urge to be compulsive with a behavior that strengthened my uncertainty tolerance (while still following CDC guidelines!).
Produce! (states of wellbeing)
Right now, somewhere on the internet, a well-intended person of privilege is sipping a fancy tea and writing a meme about how you’re supposed to come out of this pandemic having written your screenplay, learned 3 languages, and painted your house (unless you lack discipline!). That should keep you busy, but being busy is not the same thing as being productive. They are both useful (during quarantine and in general), but they are not the same thing. Being busy simply means doing things frequently. Being productive means generating something of value that did not previously exist. So while writing your movie about the tri-lingual house painter may keep your mind occupied, it’s not a given that you or others will truly benefit from the result.
What’s always guaranteed to be productive? Self-compassion and self-care. Consider a moment where you become upset about being stuck at home, anxious about the future with the pandemic, or frustrated trying to perfectly follow conflicting safety recommendations. Now imagine recognizing and making space for what you’re experiencing in your body in that moment, reminding yourself we’re all having a hard time with this, and then choosing to engage in an act of kindness towards yourself. Now that was productive.
If you’re a parent suddenly thrown into online homeschooling your children while simultaneously teleworking or maintaining a functioning household, sometimes the most productive thing to do when you get a moment to yourself is simply take that moment. Instead of doing that “one more task”, consider the wellbeing you may produce from just cutting yourself some slack. There is absolutely nothing wrong with being busy, but look for projects that end with you having produced a sense of self-appreciation, not just things that have burnt through some time. Sometimes, doing less can be more productive.
Be Good! (to yourself)
I am not an expert in coping with pandemics. I can’t imagine anyone really could be. If you struggle with OCD, anxiety, or a mood disorder, you may be really grateful for all the blogs like this, all the videos and town halls with mental health experts offering helpful advice. You may also be completely overwhelmed by the sheer volume of it and the constant reminder that there’s something you need to do to keep from falling apart. Take in what’s useful, of course, but don’t forget to consult with yourself to assess your actual needs. Maybe you’re navigating this situation well already, or maybe you just need one or two adjustments to feel more grounded through it all. If I may add to the pile of wisdom that’s being dumped on you these days, consider that you are the expert in coping with a pandemic. You are the one to determine which tools work for you right now. Be good to yourself and take it from there.
The post Be Grateful! Be Productive! Or Maybe Just Be Good to Yourself? appeared first on OCD & Anxiety Center of Baltimore | Jon Hershfield, MFT.
March 24, 2020
So Apparently This Is Happening: Mindfulness and COVID-19
It’s been pointed out to me a few times that I am disturbingly calm about all of this. Working from home during the COVID-19 crisis has given me some pause to consider why. By calm, I don’t mean disinterested or in denial. Actually, I was uncharacteristically early in this event to sound the alarm and point out the severity of what’s going on. And still, I have largely remained calm. Concerned, but calm. To be calm in the midst of a crisis is to be serious, sober, and rational. Yes, years of learning and teaching uncertainty acceptance is a factor. But I think the real explanation for this stance is simple, old-fashioned mindfulness. And now, I am more grateful for my meditation practice than ever before.
The Story Unfolds
A meditation teacher once asked me to consider that when doing a walking meditation, it is not me that’s moving, but the world that is moving in front of me. I went outside that day and walked along a trail with this in mind and noticed how each tree entered my field of vision, each gust of wind arrived at its own choosing, and each sensation in my feet simply made itself known. I was not the creator of any of this. It got me thinking about those open-world video games I sometimes enjoy. The character you play is always positioned in the center and the world of the game reveals itself as you move the character forward. You can control the direction the character goes in and the actions the character takes, but you cannot control the world that gets revealed by that movement and those actions. I think this applies to the nature of consciousness in important ways. We get overwhelmed with anxiety and frustration when the world in front of us does not reveal what we want or expect. I often find myself asking, “Why am I angry?” and then discovering the answer to be, “The universe is not doing what I told it to.”
This concept applies to more than just walking and noticing what we sense, see, or hear. It applies to our thoughts and feelings, which also arise without asking our permission. It applies to everything. We think we have control over a narrative, the movie of our life, as if we are the screenwriters, but really we are the actors. We influence the presentation with our creative responses, but we don’t write the script. This is a good thing. It means when we strive for the best “performance” in life’s movie, we are not doing so out of selfishness or narcissism, but with the quality of the entire movie in mind. In other words, your mental health, your self-compassion, your efforts to align your life with your values are for the benefit of all of us. Just like staying at home and following the scientific guidelines isn’t just about avoiding getting sick, but about keeping all of us safe.
The Script Changes
A few months ago, I was struggling with anxiety about a number of work-related projects. I was resistant to the absence of answers, angrily waiting for them to show up as if my anger would hurry their arrival. My “story” was about this, every day, for months. This is what I decided was important in so many moments where I was not otherwise distracted. Then COVID-19 arrived and said, “There’s been a change in the script.” That’s all it took. I’m walking through life thinking I control what arises and then I’m reminded that I am not being consulted at all by the universe! Like the character in the video game or the actor in the film, I cannot control what arises, only my behavior in response to it. And even if my behavior isn’t perfect- no, especially when my behavior isn’t perfect, I cannot control that discovery. I, again, can only control my behavior in response to it.
The best way to learn how to recognize when you are trying to control something that is out of your control is to learn how to meditate. If you have a meditation practice, this is the time to explore it more deeply. If you don’t have a meditation practice, this is the time to start one. If you tried meditation and it didn’t click for you, now is the time to re-approach it with intention. Intend to develop the skill of seeing thoughts as thoughts and to view the present moment without judgment. Intend to let go of predictions of catastrophe or relief and simply show up to what’s in front of you. We don’t know exactly what’s coming next. It does feel like a flying saucer has been floating above us for weeks, just menacingly charging its destruction beam, you’re right! But at least we have some power, some skill to build upon. We can improve our performance in the game by enhancing our awareness of the present. Whatever is ok now, is still ok now no matter what the future holds.
The Scene Comes Alive
As I write this from my home office between hours and hours of giving teletherapy sessions, I can look out the window and see my wife and kids walking the dog. No one else is around. That’s ok now. I miss my office, but I can step out of this room and thaw something to cook tonight. That’s ok now. We get crazy beautiful sunsets at my house and I am usually not home in time to see them. They’re ok now. I can see inside my own mind the gratitude I have for being in a profession that allows me to continue to work, that allows me to be an anchor for some people that feel swept up in this storm. That’s more than ok now. Practice catching yourself wandering into the future, creating terrain you cannot control, and come back down here, to the present moment. You can try it right now.
Notice what’s ok now.
Jon Hershfield, MFT is director of The OCD and Anxiety Center of Greater Baltimore. Follow him on Twitter, Instagram and Facebook.
For more info on this crisis and OCD, go to: iocdf.org/covid19
The post So Apparently This Is Happening: Mindfulness and COVID-19 appeared first on OCD & Anxiety Center of Baltimore | Jon Hershfield, MFT.
March 15, 2020
More Going On Than You May Think: COVID-19 and OCD
I’ve seen a lot of commentary lately about how people with obsessive-compulsive disorder (OCD) are coping with the COVID-19/Coronavirus pandemic. Some have made jokes about this being the world OCD sufferers have been waiting for, referencing the fact that some people with OCD suffer from health anxiety obsessions and catastrophic fears of contamination. But this is clearly not an educated perspective on OCD, a mental health disorder which manifests in countless obsessive themes and subthemes. Though many people with OCD do have obsessions related to contamination concerns, many of the OCD sufferers I treat struggle with intrusive thoughts about morality, violence, religion, or sexuality.
Contamination Means Many Things
For those who have what I would identify as contamination OCD, many of them do not actually have health anxiety or a pronounced fear of germs, but an exaggerated fear or disgust with bodily fluids, chemicals, or environmental contaminants. Even within that subtype, many of these sufferers are not afraid of contracting illness as much as they are afraid of violating social hygiene norms, harming others through negligence, being overwhelmed by disgust or shame, or failing to follow self-imposed rules about washing and avoidance that have nothing to do with actually being clean.
Some of my clients who compulsively wash their hands have found themselves actually reducing ritualistic washing in the midst of the COVID-19 crisis. How can this be? One reason is that compulsive handwashers are often highly aware that their behavior is excessive. Contrary to public perception and media portrayal, people with contamination OCD do not delight in washing and keeping everything clean. When they wash, they are often doing so out of desperation or a belief that they are not capable of tolerating the uncertainty over whether or not to wash. In this pressurized and anxious state, a handwash can be furious and chaotic or hyper-specific and ritualistic, and in both manifestations there is likely to be significant psychological inflexibility. What this means is that any errors in or doubts about the washing are likely to result in repetition and prolonged efforts to get it “right” before being able to stop and move on to the next task. In short, shame about washing increases compulsive washing. In the face of a scientifically mandated and culturally accepted increase in washing, this shame is reduced and so are the rituals. A 20-second handwash that’s culturally endorsed, even if unnecessary, can be more easily stopped at 20 seconds.
Many people, of course, are also having difficulty containing or navigating the frequency of their washes. This likely has to do with difficulty making moral judgments about when hands should be washed without it being explicitly laid out. For example, we all should know by now that part of appropriate social distancing, indeed our civic duty in the face of this crisis, includes washing the hands “frequently”. But if you’re anything like me, you touch your phone within five seconds of any handwash. Further, we are instructed to avoid touching the face to avoid giving the virus an opportunity to get in our eyes, nose, or mouth. But if you’re anything like me, you touch your face all the time. I can’t have an original idea without touching my face. My face is the equivalent of the touch screen on my iPad – if someone asks me for information, I touch my face to get the answer for some reason. So some people with OCD are surely having a hard time working with this word “frequency” and this word “avoid” because it appears to be without concrete limits.
Obsessing About the Virus Means Many Things
By and large, however, I have not seen a significant increase in OCD symptoms or anxiety in the people I treat, not about the virus itself anyway. The OCD-driven inquiries are more like this:
What if I touched something and didn’t realize it and this gets someone sick?
What if I think about the virus too much and this causes it to be more deadly somehow?
What if I have thoughts about wanting people to get sick or die?
What if I’m having the wrong emotional reaction to the crisis and this means I’m a bad person?
What if I feel relieved to have something different to obsess over and this means I’m callous?
The morally scrupulous OCD sufferer may find themselves over-monitoring their emotional reactions to the crisis, testing, reviewing, checking, and analyzing whether they are feeling the “right” things. Just like a person with relationship-themed obsessions may get stuck on whether they are feeling the right thing towards their partner, many OCD sufferers place enormous pressure to feel the “right” thing about an event. This is tragic, but make no mistake, what’s happening is also exciting, absurd, intellectually curious and, literally, novel. Most of us are comfortable with a variety of emotions occupying the same space, but many people with OCD suffer tremendous guilt over it and cause themselves hours a day of mental anguish.
Yet, perhaps ironically, many with OCD find a sort of relief in something bigger than their obsessions taking place. The presence of a crisis often means two things: no responsibility for the cause and little uncertainty how to respond. I am at my most relaxed when the pilot tells me we have turbulence headed our way. The pilot is in charge and my job is to stay seated. It’s when it’s not clear what my role is or what the right thing to do is that I most often fall apart.
The television show of life is not ending, but it is apparently going through an especially dark season. Every show has one. This cynical sense that the series won’t get renewed for another season can also press some OCD buttons. Those with obsessions about sexual orientation, gender identity, relationship quality, existential and religious obsessions may all feel an increase in pressure to figure it all out. OCD says you need to know you’re living an “authentic” life (whatever that means, I have no idea), and these days it may be saying you need to wrap it up already and get certain before it’s too late.
My Recommendations
I only have three recommendations to OCD sufferers who are either spiked or strangely settled by the COVID-19 pandemic:
COVID-19 has not changed the status of mental rituals. They remain pointless. Continue to practice noting when you’re ruminating and abandoning it for the present moment, whatever is in front of you.
Do what the CDC and WHO tell you to do. Don’t do more than you’ve been told just to prove you’ve done enough. If you are not sure you’ve done enough, you’ve done enough.
Many have said to limit your news intake to a few trusted sources. While I agree that compulsive checking and compulsive research should be avoided, I think you need to make this choice based on your personality. Not all people with OCD are the same. Some can derive strength and comfort from staying on top of their knowledge base and learning to distinguish between helpful information and conspiracy theories. Ask yourself what is nourishing and let self-compassion be the guide.
Only Part of the Game Has Changed
Instrumental in developing mastery over OCD is cultivating a healthy sense of skepticism of harm narratives and a loving embrace of the uncertain. This often means learning to be more impulsive, less careful, and more intentionally joyous of the present moment. Treatment for the disorder is the development of these skills. But COVID-19 has temporarily changed a few rules of this game, asking us to trust what we’re being told and be as certain as we can about social distancing. Social distancing will undoubtedly save hundreds of thousands of lives in the U.S.
So if I have one recommendation for the resilient and courageous OCD sufferers during this significant moment in history, it is to change the rules of this game only. Following the recommended guidelines does not mean mentally reviewing how well you followed them, engaging in self-punishment or self-criticism for your doubts and fears, excessive checking and reassurance-seeking, or over-washing and over-cleaning until it feels right. Accept all feelings about COVID-19, not just the ones you’d want others to know, and do the best you can to prove to the OCD that you can pivot to a change in one part of this war without sacrificing your mastery in the other parts. This is a new challenge, but you’re good at facing challenges.
For more info on this crisis and OCD, go to: iocdf.org/covid19
The post More Going On Than You May Think: COVID-19 and OCD appeared first on OCD & Anxiety Center of Baltimore | Jon Hershfield, MFT.
December 6, 2019
Demystifying Panic – Part Two
“Basically, attempts to resist these feelings teach your brain that experiencing anxiety and panic is a threat and you are unsafe.”
Part one of this blog series examined the symptoms of panic, the difference between Panic Disorder and panic attacks that occur as part of another mental disorder, and how avoidance behaviors meant to reduce discomfort can actually perpetuate panic symptoms. This continuation of the series will address the most effective, evidence-based treatment approaches for panic.
Panic is treatable!
How do I fight it? How do I get rid of it? How can I shake this feeling? It can feel as if fighting against anxiety and panic is the right thing to do, but fighting panic symptoms only makes things harder in the long term. Calling for help/ambulance, escaping your current environment, or avoiding potentially triggering people/places/events may bring you momentary relief, but when you try to forcibly stop the panic experience, it actually prolongs it. Basically, attempts to resist these feelings teach your brain that experiencing anxiety and panic is a threat and you are unsafe. Some sufferers have reported that the energy they use trying to hide the fact that they are having a panic attack can make the panic more . Of course, there may be situations where it feels too vulnerable to openly panic in front of others, and escaping or hiding your symptoms may be the better choice for you in that moment. However, always attempting to control or hide your symptoms will keep you stuck. Like a bully chasing you on the playground, if you run, the bully will just keep chasing. However, if you stand your ground, the bully will eventually back off. The keys to standing your ground are:
Acknowledge that you are feeling uncomfortable, scared, worried, etc.
Accept that those feelings are present in the body and a part of your experience.
Allow those feelings to be there until they subside naturally without fighting for control.
“I acknowledge that I am feeling very uncomfortable, scary sensations in my body, and I am worried I might panic; but, I am willing to accept these feelings because I am not in any danger, so I don’t have to try to avoid this experience.”
Cognitive Behavior Therapy for Panic
Research is well established that cognitive behavior therapy (CBT) is the most effective treatment for panic. Part of CBT is cognitive therapy, which involves modifying the way you think about an experience. Here are some common thoughts that come up for people who experience panic attacks:
I can’t do this.
I feel like I’m dying!
I’m unreliable.
I don’t want to feel this way. I just want this feeling to go away.
I think I’m going crazy!
What if I never get better and I feel this way forever?
I think I’m having a heart attack!
Recognizing when it’s unhelpful to buy in to certain thoughts is the first step in being able to reframe your thinking into more honest, useful language. In treatment, you may discover you hold on to some unhelpful core beliefs, which can be identified and changed. Challenging this negatively-biased thinking teaches the brain to back off from promoting the types of thoughts that keep you stuck. For example, “I can’t do this!” may be more accurately presented as, “This feels really hard and I don’t know for sure how things will go, but I have always gotten through the panic.”
Exposure with Response Prevention for Panic
In addition to challenging unhelpful beliefs, treatment should also include exposure with response prevention (ERP) around people/places/situations that are associated with or may trigger panic symptoms. For example, if you have been avoiding driving out of fear of having a panic attack, you will need to start driving again. It’s normal to assume you’ll start again after it doesn’t feel so scary, but it’s actually the behavior change that brings about the feelings change. You can start with small steps, such as just sitting in your car and pulling in and out of your parking spot, then build up to taking very short drives around the block a couple times a day. If doing this alone feels too hard, you may start with having a coach or safety person with you in the car. Gradually, you will give yourself permission to make longer drives with the coach or start doing the shorter drives without the coach. You can’t talk yourself into feeling better about driving or wait around until your feelings decide to change on their own — you have to actually change the behavior that gives the feelings their power. In fact, the longer you avoid driving, the stronger the narrative grows that driving causes panic attacks and must be too risky for someone like you.
You may also engage in something called interoceptive exposures, which are exposures to the physical symptoms associated with your panic attacks to help practice coping with them effectively. As discussed in part one of this series, panic attacks are typically triggered by feelings of dread around uncomfortable physical sensations or by the situations in which you experience those sensations. Additionally, you may have a belief that these physical sensations will cause you physical or mental harm. By generating the feared sensations on purpose and tolerating them, interoceptive exposures address both the erroneous belief about the physical symptoms (that they will harm you) and the distorted beliefs about the conditions where these symptoms may arise (that they are inherently dangerous). For example, increased heart rate, sweating, and shaking may be accepted, even welcomed, following a great workout or when you feel excited in anticipation of some desired event. However, you may view those same physical sensations as dangerous when feeling anxious. In treatment, a therapist may invite you to engage in an activity to intentionally raise your heart rate, have you cover yourself with a blanket to make you feel too warm, or have you breathe through a straw to stimulate feeling lightheaded or shaky. When experienced outside the context of anxiety, these symptoms gradually begin to lose their catastrophic meaning.
Mindfulness for Panic
In addition to challenging distorted beliefs and engaging in exposures to feared conditions, engaging in mindfulness skills training is very effective at improving one’s ability to recognize resistance to panic and, ultimately, to let go of that resistance. Mindfulness is the skill of observing your experience (internal and external) exactly the way it is in the present moment. By doing this you can recognize when your attention is stuck on fear and panic and, instead of trying to push that away, you can open up your attention to something else in the present moment. In other words, you can notice panic symptoms and choose to do valued things, rather than get consumed by the story of panic in your head.
What About the Breathing?
Breathing is a good thing, and I highly recommend you continue to do it for as long as possible! When it comes to engaging breathing modification during panic attacks, different experts have different approaches. Some believe that controlling breathing during a panic attack helps one take in enough air, with the right ratio of oxygen to carbon dioxide to slow down the panic cycle. Some experts believe it’s more helpful to simply sit with the anxiety without engaging in any behaviors aimed at reducing it on your own – because you aren’t in danger. Studies are not conclusive that breathing training increases the effectiveness of CBT. What studies do show is that successful treatment doesn’t involve treating the overwhelming sensations themselves, but is all about effectively reframing flawed, catastrophic beliefs about those sensations, (i.e., feeling queasy or short of breath does not automatically mean fainting and vomiting), (Meuret, Wolitzky-Taylor, Twohig, & Craske, 2012). What some of my clients have found helpful is engaging in deep diaphragmatic breathing during a panic attack because it helps them to think a little more clearly and remind themselves that, while very uncomfortable, they are in no danger of dying or going crazy. Focusing on controlled breathing also gives them something to anchor their attention on (mindfulness) instead of remaining stuck in the mental story of fear and panic.
Panic attacks are scary, unwanted, and sometimes truly life disrupting, but you are not a lost cause. Panic is treatable and you are more resilient than you think!
Brenda Kijesky, LCMFT is a psychotherapist specializing in OCD and related disorders at The OCD and Anxiety Center of Greater Baltimore.
Click HERE for Part One of Demystifying Panic
References
Meuret, A.E., Wolitzky-Taylor, K.B., Twohig, M.P., & Craske, M.G. (2012). Coping Skills and Exposure Therapy in Panic Disorder and Agoraphobia: Latest Advances and Future Directions. Behavior Therapy, 43(2), 271–284.
The post Demystifying Panic – Part Two appeared first on OCD & Anxiety Center of Baltimore | Jon Hershfield, MFT.
October 10, 2019
Having Real Conversations: Working With Your Non-OCD Partner
“Discussing in an honest way what made this situation difficult to talk about allowed us to be open to what the other had to say and to treat each other with the compassion and respect that we both deserved.”
Recently, I had an experience that was both tremendously anxiety producing and incredibly beneficial. While I typically wouldn’t share this sort of thing with the entire universe, I feel driven to write about this personal situation. I consider myself to be in a unique position to discuss communicating effectively when one has OCD, as I am a person who has OCD, and I have also been impacted by growing up with a parent with untreated OCD.
So, here goes! I was stunned when I found out that we had bed bugs living in our mattress. The topic of bed bugs was very familiar to me, as it had been one of the many topics that seemed to be on rotation with my OCD. In the past though, we never actually had bed bugs. In fact, I had done exposures to the topic of having bed bugs several years earlier and for the most part was completely free from worrying about them. Finding out this time that we actually did have bed bugs presented quite a challenge initially. I was well aware of the countless times I have said, “this time is different”, but this was my first experience where it legitimately seemed different.
While I think my response to the situation was fairly typical, there were times where my OCD tried to infiltrate it by demanding that I (which really always meant “we” – my husband and I) follow a very extreme protocol. This protocol included getting rid of a piece of furniture that we both loved. As a result, my husband and I agreed to sit down and discuss the situation. This blog is born from this conversation.
Calling a Spade a Spade
My husband asked me if I thought we should start by setting some guidelines for a safe conversation and if so, what would I tell my clients and their families faced with similar circumstances? His seemingly obvious question took me aback. I really didn’t have an immediate answer. While talking about communicating is always some part of treatment, I had not come across a situation with clients where the content of one’s OCD was also a “real life” issue. It seemed like a great opportunity to illustrate how to work collaboratively to improve communication when one person has OCD and the other does not. It can make all the difference when it comes to keeping the disorder from dominating otherwise productive conversations.
The first step was acknowledging that the situation was very difficult for both of us. The pain of the OCD sufferer is often quite obvious, but it is easy to overlook how exasperating and distressing it can be to be on the receiving end of the sufferer’s persistent claims of imminent disaster. Having some guidelines established can be a healthy way to acknowledge the needs of both the individual with OCD and their loved one.
Establishing the terms
One of the painful things I remember about my upbringing was waiting for my mom’s OCD to allow her to come out of her room so that we could move forward. OCD was the great decider. It didn’t matter how much she loved us or how much she wanted us to have a normal family life. If OCD said she needed to do one more compulsion, then that is what happened. I really didn’t understand as a child that it didn’t feel like a choice for her.
As someone who treats OCD, and has also had treatment for OCD, I think it is important to say that, even after treatment, there will be times when OCD tries to hijack everyone’s attention. Setting some basic guidelines for the conversation based on mutual goals (as well as individual needs) can set the stage for a respectful conversation where both parties feel heard.
“Setting guidelines” probably sounds really official, but these are not meant to be rigid rules (like OCD loves). Rather, they are general principles that both people agree to keep in mind during the conversation. For example, those that have OCD may not know how they come across to their loved one when they are anxious; that the look on their face may be one of sheer panic, anger, or despair. It can be helpful to talk about how these emotions will be addressed in advance.
For the person with OCD, you may already know that your OCD is involved and you fear that your loved one will ignore your concern, chalking the entire thing up to your disorder. In my situation, I wanted it to be acknowledged that we actually did have a problem (bed bugs) and that it wasn’t all my OCD. I wanted to feel heard. If you are the one without OCD, you may be concerned about how to listen only once without being accused of minimizing the situation or not hearing what was said. You also want to come up with a solution to the actual problem, not the part of it that is OCD. What can be helpful is to recognize that you both want the same thing, not to be taken hostage by OCD.
Key points to consider before difficult conversations:
What are your mutual goals for the conversation?
How do you, as a team, want to deal with insistence and repetition if/when they crop up?
How will you convey to each other that you have heard what the other has said?
How do you want to handle it if/when OCD begins to flare up?
How do you know when you need to pause the conversation for a period of time?
How do you come to a reasonable decision both can agree to?
How do you address requests for reassurance?
The answers above will vary based on the nature of the relationship and the situation. It may be useful to decide in advance how many (if any) reassurance questions will be responded to and what a supportive statement might sound like if one of you respectfully disagrees with a point without feeling dismissed or unheard. I found that being willing to pause and consider these challenges helped me to be mindful during the conversation so I could better focus on what was real and what was OCD.
It wasn’t too difficult to recognize which things were demands of my OCD versus reasonable guidelines that were necessary to address the problem. For example, we were informed that bed bugs are killed at high temperature and one recommendation was to put linens, pillows and towels in the dryer at the highest setting. But OCD said if once is good than certainly 2, 3, 4, and so on… would be better. OCD also began to whisper that it was reasonable to put everything that ever might have been on the floor into the dryer, including items that were already cleaned and dried. Of course the worst of all was my advisor, Google, who never stopped providing new and wonderful ways these superpowered creatures might be lying dormant, ready to come out 6 months later for a “bloodmeal” (isn’t that the worst word ever?). The panic and urgency had set in, and I needed some help.
The Endgame
My first inclination had been to treat the situation as a national crisis! It felt like an emergency. OCD was shouting its national anthem, “oh, say can you see, that disaster is imminent…no, it’s not… yes, it is!” This was nothing new to me. While I have the knowledge and training to identify this obvious OCD prank, it was helpful to have my husband (who has an honorary blackbelt in understanding OCD language) to remind me that this was not an actual emergency. Our house was not on fire, we just had some bugs. It was a bummer, but nothing exciting.
Together we came up with a game plan that addressed the real problem without allowing OCD to make all the rules and decisions. We decided to hire extermination professionals and follow their guidelines. In regard to the questionable piece of furniture, my husband proposed that we ask the professionals about what we should do with the furniture, and then do whatever guidelines they suggested.
A Winning Hand
One of the most painful things about having OCD is the way the disorder can make you feel isolated and alone, as if you, and you alone, are in a private nightmare. When I was young, my whole family would rally around my mom offering what we believed to be support but was actually reinforcing her anxiety and ultimately keeping her stuck. We didn’t know how to help her. My husband’s simple gesture was an act of support and genuine compassion, because he was able to convey to me that he empathized with how difficult the situation was. But at the same time he was not going to allow OCD to make our decisions. Rather than dictating how the conversation should go, he offered some simple suggestions for me to consider.
In the end, anticipating and identifying the challenges that can arise allowed us to collaborate and come up with a game plan that we both could agree was reasonable. Discussing in an honest way what made this situation difficult to talk about allowed us to be open to what the other had to say and to treat each other with the compassion and respect that we both deserved. I once thought that having bed bugs was one of the most horrible things that could happen. Now I think experiencing them first hand has given me more confidence in myself and my family’s ability to deal with whatever cards we are dealt.
Molly Schiffer, LCPC is a psychotherapist specializing in OCD and related disorders at The OCD and Anxiety Center of Greater Baltimore.
The post Having Real Conversations: Working With Your Non-OCD Partner appeared first on OCD & Anxiety Center of Baltimore | Jon Hershfield, MFT.
September 23, 2019
Having Real Conversations: Working With Your Non-OCD Partner
“Discussing in an honest way what made this situation difficult to talk about allowed us to be open to what the other had to say and to treat each other with the compassion and respect that we both deserved.”
Recently, I had an experience that was both tremendously anxiety producing and incredibly beneficial. While I typically wouldn’t share this sort of thing with the entire universe, I feel driven to write about this personal situation. I consider myself to be in a unique position to discuss communicating effectively when one has OCD, as I am a person who has OCD, and I have also been impacted by growing up with a parent with untreated OCD.
So, here goes! I was stunned when I found out that we had bed bugs living in our mattress. The topic of bed bugs was very familiar to me, as it had been one of the many topics that seemed to be on rotation with my OCD. In the past though, we never actually had bed bugs. In fact, I had done exposures to the topic of having bed bugs several years earlier and for the most part was completely free from worrying about them. Finding out this time that we actually did have bed bugs presented quite a challenge initially. I was well aware of the countless times I have said, “this time is different”, but this was my first experience where it legitimately seemed different.
While I think my response to the situation was fairly typical, there were times where my OCD tried to infiltrate it by demanding that I (which really always meant “we” – my husband and I) follow a very extreme protocol. This protocol included getting rid of a piece of furniture that we both loved. As a result, my husband and I agreed to sit down and discuss the situation. This blog is born from this conversation.
Calling a Spade a Spade
My husband asked me if I thought we should start by setting some guidelines for a safe conversation and if so, what would I tell my clients and their families faced with similar circumstances? His seemingly obvious question took me aback. I really didn’t have an immediate answer. While talking about communicating is always some part of treatment, I had not come across a situation with clients where the content of one’s OCD was also a “real life” issue. It seemed like a great opportunity to illustrate how to work collaboratively to improve communication when one person has OCD and the other does not. It can make all the difference when it comes to keeping the disorder from dominating otherwise productive conversations.
The first step was acknowledging that the situation was very difficult for both of us. The pain of the OCD sufferer is often quite obvious, but it is easy to overlook how exasperating and distressing it can be to be on the receiving end of the sufferer’s persistent claims of imminent disaster. Having some guidelines established can be a healthy way to acknowledge the needs of both the individual with OCD and their loved one.
Establishing the terms
One of the painful things I remember about my upbringing was waiting for my mom’s OCD to allow her to come out of her room so that we could move forward. OCD was the great decider. It didn’t matter how much she loved us or how much she wanted us to have a normal family life. If OCD said she needed to do one more compulsion, then that is what happened. I really didn’t understand as a child that it didn’t feel like a choice for her.
As someone who treats OCD, and has also had treatment for OCD, I think it is important to say that, even after treatment, there will be times when OCD tries to hijack everyone’s attention. Setting some basic guidelines for the conversation based on mutual goals (as well as individual needs) can set the stage for a respectful conversation where both parties feel heard.
“Setting guidelines” probably sounds really official, but these are not meant to be rigid rules (like OCD loves). Rather, they are general principles that both people agree to keep in mind during the conversation. For example, those that have OCD may not know how they come across to their loved one when they are anxious; that the look on their face may be one of sheer panic, anger, or despair. It can be helpful to talk about how these emotions will be addressed in advance.
For the person with OCD, you may already know that your OCD is involved and you fear that your loved one will ignore your concern, chalking the entire thing up to your disorder. In my situation, I wanted it to be acknowledged that we actually did have a problem (bed bugs) and that it wasn’t all my OCD. I wanted to feel heard. If you are the one without OCD, you may be concerned about how to listen only once without being accused of minimizing the situation or not hearing what was said. You also want to come up with a solution to the actual problem, not the part of it that is OCD. What can be helpful is to recognize that you both want the same thing, not to be taken hostage by OCD.
Key points to consider before difficult conversations:
What are your mutual goals for the conversation?
How do you, as a team, want to deal with insistence and repetition if/when they crop up?
How will you convey to each other that you have heard what the other has said?
How do you want to handle it if/when OCD begins to flare up?
How do you know when you need to pause the conversation for a period of time?
How do you come to a reasonable decision both can agree to?
How do you address requests for reassurance?
The answers above will vary based on the nature of the relationship and the situation. It may be useful to decide in advance how many (if any) reassurance questions will be responded to and what a supportive statement might sound like if one of you respectfully disagrees with a point without feeling dismissed or unheard. I found that being willing to pause and consider these challenges helped me to be mindful during the conversation so I could better focus on what was real and what was OCD.
It wasn’t too difficult to recognize which things were demands of my OCD versus reasonable guidelines that were necessary to address the problem. For example, we were informed that bed bugs are killed at high temperature and one recommendation was to put linens, pillows and towels in the dryer at the highest setting. But OCD said if once is good than certainly 2, 3, 4, and so on… would be better. OCD also began to whisper that it was reasonable to put everything that ever might have been on the floor into the dryer, including items that were already cleaned and dried. Of course the worst of all was my advisor, Google, who never stopped providing new and wonderful ways these superpowered creatures might be lying dormant, ready to come out 6 months later for a “bloodmeal” (isn’t that the worst word ever?). The panic and urgency had set in, and I needed some help.
The Endgame
My first inclination had been to treat the situation as a national crisis! It felt like an emergency. OCD was shouting its national anthem, “oh, say can you see, that disaster is imminent…no, it’s not… yes, it is!” This was nothing new to me. While I have the knowledge and training to identify this obvious OCD prank, it was helpful to have my husband (who has an honorary blackbelt in understanding OCD language) to remind me that this was not an actual emergency. Our house was not on fire, we just had some bugs. It was a bummer, but nothing exciting.
Together we came up with a game plan that addressed the real problem without allowing OCD to make all the rules and decisions. We decided to hire extermination professionals and follow their guidelines. In regard to the questionable piece of furniture, my husband proposed that we ask the professionals about what we should do with the furniture, and then do whatever guidelines they suggested.
A Winning Hand
One of the most painful things about having OCD is the way the disorder can make you feel isolated and alone, as if you, and you alone, are in a private nightmare. When I was young, my whole family would rally around my mom offering what we believed to be support but was actually reinforcing her anxiety and ultimately keeping her stuck. We didn’t know how to help her. My husband’s simple gesture was an act of support and genuine compassion, because he was able to convey to me that he empathized with how difficult the situation was. But at the same time he was not going to allow OCD to make our decisions. Rather than dictating how the conversation should go, he offered some simple suggestions for me to consider.
In the end, anticipating and identifying the challenges that can arise allowed us to collaborate and come up with a game plan that we both could agree was reasonable. Discussing in an honest way what made this situation difficult to talk about allowed us to be open to what the other had to say and to treat each other with the compassion and respect that we both deserved. I once thought that having bed bugs was one of the most horrible things that could happen. Now I think experiencing them first hand has given me more confidence in myself and my family’s ability to deal with whatever cards we are dealt.
Molly Schiffer, LCPC is a psychotherapist specializing in OCD and related disorders at The OCD and Anxiety Center of Greater Baltimore.
The post Having Real Conversations: Working With Your Non-OCD Partner appeared first on OCD & Anxiety Center of Baltimore | Jon Hershfield, MFT.
September 11, 2019
Jon on Retreat: Part Two
In Part One of this blog series on meditation retreats, I described my first experience at the Insight Meditation Society in Barre, Massachusetts. For roughly three weeks after that retreat, I continued to be strongly affected by the insights gained from the three days of silent meditation and mindfulness instruction. The things I typically try to do in my life to “be good” or to be healthy, compassionate, and present-minded; they take effort. But for these three weeks, they appeared largely effortless. I gradually returned to my conditioned ways of being, which is fine, but it got me interested in intensive meditation experiences. I used to work in an intensive outpatient program where children with OCD would focus 3-hours a day on their treatment and then go home and do even more ERP homework. I remember thinking that no one can really live that way forever, but maybe if they could live that way for a short period of time, all they really needed to do was remember that that is a way to be. Mindfulness and meditation are much the same way. I don’t need to meditate all day to be mindful. I just need to remember what it is like to have a mind at rest, to remember that I can tell the difference between a thought and a threat.
I Learn Something New Every First Time
Since those illuminating three days last September, I have been on four more retreats: a 2-day with Hugh Byrne and a 7-day in with Tara Brach and Jonathan Foust, both sponsored by the Insight Meditation Community of Washington in Maryland, a 5-day with Michael Grady and Jean Esther and another Labor Day weekend (this time with Bonnie Duran and Winnie Nazarko) again in Barre. Working with different teachers is illuminating. Like many mindfulness books, having the same thing expressed in different ways makes it more likely to stick.
Every retreat experience is different and the same; different in that I learn something new, and the same in the sense that the mind follows predictable patterns. On my first retreat with Anushka Fernandopulle and Pascal Auclair, I felt I got my first peek at the truth, that all we have is the present moment and OCD lives in the space between our experience of the present and our stories. The teachers didn’t tell me this, but simply facilitated the space for the insight to arise. On my second retreat, a short 2-dayer, I learned that the less I do, the more I accomplish. Getting away from my distractions, not just my phone, but nearly all of my “activities” clearly demonstrated that the mind yearns for space to grow and distractions limit it. On my third retreat, 5 days in Barre, I learned more about self-compassion and how nonsensical and yet deeply ingrained hostility towards the self can be. On my week-long, which included an emphasis on body-focused inquiry, I came away with insights about how much we miss when we view the mind and body as separate. On the 3-day retreat this Labor Day weekend, I learned that I don’t have to define myself by my thoughts, my body, or my job. I don’t have to define myself, full stop.
Taking OCD Along
I had the new experience of going into retreat this most recent time with an active obsession. In the anticipatory build-up to the break from a stressful work-week, I got stuck on something just before I left. Generally, when you immerse yourself in mindfulness meditation, the mind naturally wanders to a wide variety of stories, like cable tv channels; stories about your childhood, your relationships, mistakes you’ve made, and everything from your wildest fantasies to whether or not you’re finally going to get your car washed next weekend. But when you enter a mindfulness meditation retreat with an active obsession, something that really triggered your OCD, your mind wanders from the present moment to one channel only. It’s as if all of your subscriptions have been cancelled except that one station that plays that one movie over and over and over again. You attend to the breath, you attend to the sensation of walking, the food you are eating, to the feeling of having a body – and you attend to that one thing.
Of course, this is what it’s like when you have an active obsession out in the real world, except in the real world you have an unlimited supply of distractions. You can abandon rumination, mental review, mental checking, mental repeating, retracing, rehearsing, thought neutralization, rationalization, self-reassurance (need I go on?) for your favorite song, your social media, or your stupid email. On a meditation retreat, it’s just you, the mind/body experience, and your OCD. But here’s the interesting thing about mindfulness and meditation when you have an active obsession – it doesn’t matter. If you want the mind to rest, you still simply begin again (as Joseph Goldstein is fond of saying on the 10% Happier app). And the fascinating part of this is that because an obsession clouds out everything else the mind would bother with, you can literally witness it fade away in the retreat environment. People often ask me how they will know when they’ve overcome their OCD and I usually respond that they’ll know when they stop checking to see if the obsession is still there. But I discovered in this environment, on retreat in noble silence, just me and my obsession, that it is possible to actually witness an obsession exit consciousness. Put another way, it is possible to witness the mind coming to rest more clearly when an obsession gives the mind fewer places to go.
Awful Until Awesome
Day one of every silent meditation retreat is not easy. For one thing, because your body is so used to being deprived of rest from all your big important tasks that need to get done, it takes every opportunity to conk out when you meditate. The mind goes into a state that is sometimes referred to in Buddhist circles as “sloth and torpor.” Sometimes it’s actual sleep and sometimes it’s more like struggling to keep your head above quicksand. You sit there and you watch the breath and then your head slumps, and then you realize you’re dreaming, and then you jolt up and pretend to cough and then try really hard to think about breathing again. It sucks. Jonathan Foust referred to this as “whiplash meditation” the way your head snaps back when you discover you’ve dozed off. This inability to stay focused is frustrating because you lose the ego-driven pride of how cool you are as a “professional meditator” and find yourself in perpetual FOMO. Worse, all of your unwanted stories (or that one story your OCD is attached to) just sit there, and there’s no escape.
Day two, somewhere between lunch and the end of the day, your mind acquires some kind of learned helplessness and comes to the conclusion that resisting your stories being there is pointless. There’s just not much to do about it in this environment. This has been my experience on every retreat thus far, though the most recent one with my OCD in high gear had me convinced I was doomed (until I stopped being convinced). You just can’t pretend you’re going to out-think the OCD. You begin to accept that the thoughts and feelings you’re having are just objects of attention to be observed. In other words, the mind becomes a screen, your stories become movies, and you become an audience. This doesn’t mean you stop getting carried away. I cry, jump, and laugh out loud when I watch actual movies (usually all in the same scene). In other words, I wander into the delusion that something is happening other than lights projected on a wall portraying actors pretending to have experience. But, as when at the cinema, I don’t stay in the delusion for very long. I always come back to my popcorn. This freedom to be entertained by your mind when it wanders away leaves you feeling pretty good. If you’re on a retreat for 3 days or more, the next few days feel pretty giddy. Love starts to be the only logical stance, whether it’s love for your family, yourself, that guy sitting behind you on retreat who swallows loudly every ten seconds (Swally McSwallowerson, I called him), or even your OCD.
Maybe Not
On my longer retreats, of 5 or 7 days, the experience cycles back into a dark space again. All things are impermanent, even nice things. This is because after a few days of being high on life and thinking of the lyrics to The Flaming Lips’ “Do You Realize?” every time you see a human face, doubt starts to roll in. Am I in a cult? I did just bow to a statue. Is this just me avoiding my responsibilities and abandoning my work, family, and the rest of it? However, given that the mind has learned to rest and observe, you can see doubt itself as just another object of attention. The implications for OCD are profound. When we choose to resist compulsions in response to our triggers, we are always faced with doubt. Maybe this isn’t OCD, we think. Maybe this is OCD, but I’m still doing something wrong. Maybe the pain of doubt is trying to tell me that this time we’re headed for some truly intolerable pain. But if doubt can come and go like a song on the radio, then all we have to do is notice. Saying, “I am in doubt” is living under the thumb of OCD, but saying, “I see doubt” is true freedom.
Read Part One of “Jon on Retreat” HERE
Jon Hershfield, MFT is a psychotherapist and director of The OCD and Anxiety Center of Greater Baltimore. Follow him on Twitter and Facebook.
P.S. On my 5-day retreat, I had a song stuck in my head that attached itself to my in-breath and out-breath for several days. In, and I experienced the song, out, and I experienced the song. I could remember the name of the artist, but not the name of the song, so I looked it up as soon as I got home. It was, ironically, called Empty Lungs. (https://www.youtube.com/watch?v=avPMl_JFwag).
The post Jon on Retreat: Part Two appeared first on OCD & Anxiety Center of Baltimore | Jon Hershfield, MFT.
July 7, 2019
How Having No Cure Is the Cure
The DSM-V is a catalog of mental health disorders as determined by the American Psychiatric Association with the input of many mental health experts around the world. The way it works is it identifies symptoms (behaviors we engage in and our internal experience of thoughts, feelings, and sensations) and clusters them into groups. It then adds to that a number of relevant factors, such as how long you may have had these symptoms, how long they tend to last, and how much impairment they cause you. If you have a number of symptoms in the cluster and a number of the additional relevant factors, then you have something called a disorder, or a mental health condition. I have one, apparently, or so have said every mental health professional I have asked help from. Being able to name disorders is essential for being able to study them, which is how we identify the treatments that are most likely to be effective. A treatment is considered effective when it results in a reduction of the symptoms and other factors that make up the disorder. By definition, once the symptoms and other factors fundamentally change or reduce, the disorder ceases to exist per the definition in the DSM-V.
But is this a cure?
The answer is complicated, because a funny thing happens on the way to this debate. It turns out the most effective treatment for OCD, the name of the disorder that explained to me what was causing so much unnecessary suffering, is cognitive behavioral therapy (CBT) with an emphasis on exposure and response prevention (ERP). What happens in CBT with ERP is you learn how to navigate your experience differently, how to confront your fears and how to choose different behaviors in response to your thoughts, feelings, and sensations than you might instinctively choose. More specifically:
Notice that thinking is a behavior and that different ways of thinking about your experience may make you more or less likely to choose effective behavioral responses
Recognize that you are not a bad person for having unwanted thoughts, feelings, and sensations, that these experiences are part of being human and that blaming yourself for them is part of your disorder’s thinking style
Lean in, open up, embrace, and even celebrate your unwanted thoughts, feelings, and sensations because this gives them free passage through your mind instead of keeping them stuck
Practice staying with and observing urges to get reassurance, avoid, wash, clean, review, etc. so you can be a witness to the coming and going nature of these urges and stop responding to them like they must be sated or destroyed
Learn to appreciate yourself for who and how you are, and instead of devoting every waking moment to getting rid of your unwanted thoughts, train yourself to instinctively invest in the present moment as it is, and take the risk of accepting uncertainty
All of the above are desired outcomes of CBT and ERP and for a significant number of OCD sufferers, these outcomes are truly accessible and really result in a reduction of the symptoms and other factors that define having OCD. So you might presume that this means CBT with ERP cures the disorder because it disqualifies you from meeting the American Psychiatric Associations definition of the disorder.
But there’s an ironic twist.
In order for any or all of the above to occur, you fundamentally must foster an identity that frames OCD as a part of who you are, not a thing that’s broken about you. Believing that you’re defective merchandise to be taped up and put back on the shelf is the mentality that leads to self-hatred and more compulsive behavior. Believing that you are a “loudthinker” (what I called myself in online support groups during my treatment), and that embracing all of the above leads to mastery of this OCD experience, is what actually makes the treatment stick. The best CBT and ERP in the world shoots you down the path to this mastery, but the rest is a life’s work.
My kids are super cute and fill me with pride every day. When I catch either of them at their most spectacular, I think two things with regularity: 1) I am the luckiest dad alive and 2) I am going to die early, probably in front of them, and their lives will be defined by having lost their father. I no longer meet the DSM’s clinical criteria for OCD, so the book can tell me I don’t have OCD, and I am not distressed by that second thought at all. I expect nothing else and if it gets any rise out of me, it’s a laugh. Didn’t used to be that way. I used to spend an inordinate amount of time crying and not being able to explain to people why (or worse, being able to explain it to them and having them tell me that’s not a reason to be upset). Thanks to CBT and ERP, and obviously mindfulness, I don’t have to do the things I used to do that earned me the DSM’s label. I don’t have OCD, but only because I know that I have OCD.
I still get stuck in stories from time to time.
We call these relapses. They commandeer my attention for a few days at a time and they come up 2-3 times a year. I don’t meet the criteria for OCD, but I have OCD relapses. Even in the eye of an OCD storm, I score too low on the impairment, resistance, and control measurements of the Yale Brown Obsessive Compulsive Scale to be considered clinically significant. Even when my OCD is at its worst, I apparently don’t “have” OCD. Even right now, noticing the italicized word in the last sentence does not have an italicized quote at the beginning, but does at the end, I apparently don’t have the DSM’s OCD. I’m not going to fix the typo. This choice isn’t because I was cured of the disorder. This choice is because I understand that I have the disorder. It is a part of what I am and understanding this is what made treatment work!
So in the end, the “cure” for OCD is to understand that there is no such thing as a cure for OCD. There is no thing to be cured. There are thoughts, feelings, and sensations, and by being a student of them instead of a victim of them, you can change your relationship to them and live a joyful, mostly unimpaired life. When you do this, you get dumped by the DSM. The book can call me cured. But if I want to stay cured in the book’s eyes, I must, categorically, call myself something else. Perhaps I can just identify myself as being somewhere along the path to mastery of my mind. That is, my mind, the one with OCD.
Jon Hershfield, MFT is a psychotherapist and director of The OCD and Anxiety Center of Greater Baltimore. Follow him on Twitter and Facebook.
P.S. Inspiration and input from Shala Nicely, LPC on this subject was an essential ingredient in the post above.
The post How Having No Cure Is the Cure appeared first on OCD & Anxiety Center of Baltimore | Jon Hershfield, MFT.
July 2, 2019
Demystifying Panic: Part One
While these symptoms may make you feel as if you’re going crazy, you are anything but crazy. You may think that you are the only one who experiences these feelings; however, you are far from alone.
“OMG, I’m dying!”
“I think I’m having a heart attack!”
“People probably think I’m crazy!”
“I’m afraid I’m going to pass out!”
“It’s happening again!”
“I can’t breathe!”
If you’ve ever experienced a panic attack, you know it can be a very distressing rush of extreme anxiety accompanied by uncomfortable physical sensations and negative thinking. So what exactly are panic attacks? The DSM-V (a book that catalogs the criteria for mental health disorders) describes a panic attack as a discrete period of intense fear or discomfort, in which at least four of the following symptoms showed up abruptly and reached a peak within minutes:
Palpitations, pounding heart, or accelerated heart rate
Sweating
Trembling or shaking
Sensations of shortness of breath or smothering
Choking feeling (tightness in throat)
Chest pain or discomfort (tightness or feeling a heavy weight)
Nausea or abdominal distress (churning stomach, need to use the toilet)
Feeling dizzy, unsteady, lightheaded, or faint (ringing in the ears)
Chills or heat sensations
Numbness or tingling sensations
Derealization (feelings of unreality) or depersonalization (being detached from oneself – like you’re not connected to your body)
Fear of losing control or ‘going crazy’
Fear of dying (sense of dread or “doom”)
While these symptoms may make you feel as if you’re going crazy, you are anything but crazy. You may think that you are the only one who experiences these feelings; however, you are far from alone. Panic attacks are quite common – in a given year, about 11.2% of adults experience at least one panic attack. According to the National Institute of Mental Health (NIMH), 22.7% of U.S. adults will experience a panic attack in their lifetimes. Panic attacks commonly last anywhere from a couple minutes to 20 minutes; although in some rare instances, they may last up to a few hours.
Frequently, panic attacks start with an identifiable trigger.
Case Example: Jennifer
Jennifer is 32 years old and has been diagnosed with OCD. Her obsessions tend to evolve around perfection – wanting to do things perfectly and appear perfect to others. Jennifer’s job requires giving occasional presentations to her management team. When she has an upcoming presentation, she spends a significant amount of time re-checking her work and rehearsing because OCD tells her that it’s not okay to make a mistake or appear as if she doesn’t know everything. Before the presentation, she starts to feel anxious and notices uncomfortable sensations in her body – heart pounding, stomach churning, feeling light-headed – and views those symptoms as a sign that the presentation is going to go terribly, which will lead to panic, and, ultimately, the loss of her job. She engages with that fear by giving it a lot of attention, desperately trying to get it to go away, which triggers even more physical arousal and then, she panics! Her heart rate jumps through the roof, she feels like she can’t breathe, her mind becomes flooded with thoughts of going insane and dying. She tells her boss she’s ill and someone has to cover for her. The panic symptoms eventually subside, but now Jennifer believes that these presentations are something to be feared and avoided because they trigger panic attacks.
Panic Attacks or Panic Disorder?
Panic attacks can occur within a number of mental disorders, such as OCD, anxiety and related disorders, depressive disorders, trauma, bipolar disorders, impulse-control disorders, and substance-use disorders. The case example above demonstrated how a panic attack might be triggered by an unhelpful response to anxiety and OCD. However, to meet criteria for Panic Disorder, panic attacks must be both recurrent and unexpected. Recurrent simply means more than one panic attack has occurred. Unexpected means there is no clear trigger for the panic attack, such as a feared social situation (like Jennifer’s) or a stimulus that feels inherently dangerous. In Panic Disorder, panic attacks may occur when you are comfortably relaxing at home, or even at night, waking you out of a sound sleep for no apparent reason. People with Panic Disorder also engage in persistent worry about future panic attacks and their consequences and engage in strategies to avoid situations that may trigger more attacks.
Why do I feel this way?
Panic attacks are typically triggered by feared beliefs about uncomfortable physical sensations (i.e., heart pounding, stomach churning) or by conditions where one experiences these sensations (Clark, 1986). For example, you may notice yourself anticipating a panic attack if your stomach starts to churn before a job interview or if you feel jittery and have heart palpitations after drinking too much Red Bull the night before a big test. In some cases, a medical condition, hormonal change, or medication side effect can also trigger these symptoms. People with Panic Disorder typically have strong beliefs and fears that the physical sensations associated with panic attacks will cause physical or mental harm (Chambless, Caputo, Bright, & Gallagher, 1984), (McNally & Lorenz, 1987); hence, the common belief that a racing heart may trigger a heart attack or “butterflies” in the stomach means you will definitely vomit. This may explain why a medication side effect such as nausea can appear to trigger panic attacks in some. In other words, the automatic interpretation of the nausea may light up the panic center of the brain in a susceptible person.
People who have Panic Disorder are more likely than the general population to catastrophize the experience of uncomfortable physical anxiety symptoms (Clark et al., 1988), meaning they predict a negative future outcome that they assume cannot be coped with. For example, you may believe that you will never be able to go to work feeling this way and, therefore, you’ll have to be dependent on others for the rest of your life. When the emotional brain senses a threat, it signals your nervous system to engage and keep you safe by giving you increased strength and speed. It’s basically an adrenaline rush. When the emotional brain senses that the perceived threat has passed, the anxiety comes down. How this “rush” is interpreted can make a big difference.
The Truth About Your Attacks
Panic attacks are not dangerous.
Panic attacks will not make you go crazy.
Panic attacks will not cause heart attacks. They are just a sudden burst of intense energy that can feel extremely uncomfortable.
All panic attacks end! It is not physiologically possible for that feeling to continue forever because the body cannot sustain that level of energy usage for very long.
So, Fear of Panic Attacks Brings on Panic Attacks?!?
Panic attacks can feel extremely scary. Typically, it’s the concerns about what the physiological symptoms may mean, the concerns about social consequences (what other people would think of you), and/or the fears about “going crazy” that perpetuate the fear. The more the panic attacks occur, the more you fear having another attack, and that is what increases their frequency. The more you try to run away from a panic attack, the more it will chase you. What can feel the scariest is the sense of no longer having control during a panic attack. When experiencing a sense of danger/doom or fear of dying, escape feels like the only option.
The cycle may look something like this: You experience some kind of uncomfortable bodily sensation > you think, “Oh, I’m anxious!” > your body further responds to the belief that you are anxious and you experience more uncomfortable sensations > you start predicting what horrible thing will happen if you panic > you feel even more anxious > you notice more uncomfortable sensations > the cycle revs up and you have a panic attack!
Or this: You walk into the grocery store where you’ve experienced panic before and think, “What if I panic, again, and can’t go to the grocery store anymore?” > you notice physical symptoms of anxiety in response to that thought > those sensations are your evidence that you are going to panic > you decide to stay close to the exit in case you need to escape > your body becomes more aroused > panic attack!
Avoidance is a Trap
The fear of panic often leads people to avoid things that are important to them, such as going out with friends, going to concerts, places of worship, exercise, etc. Sometimes, the avoidance behaviors become so pervasive that people stop engaging in essential daily activities such as going to work or running errands. Persistent avoidance of places that are associated with panic attacks may lead to a disorder called Agoraphobia (fear of being outside). It’s a myth that you can stop panic attacks simply by changing your environment. If you flee wherever you are when you are panicking, you may spare yourself short-term pain; however, you are reinforcing the belief that panic symptoms themselves are a threat, which will exacerbate the cycle.
But you don’t need to live your life in perpetual fear of the next attack. By first understanding the common shared experience of panic attacks and how our instinctual urges to avoid them can perpetuate them, you now have the power to begin to demystify them. What may seem uncontrollable and more powerful than you now can be overcome.
Part Two of this blog will discuss some of the effective therapeutic techniques for taking command of this treatable condition.
Brenda Kijesky, LCMFT is a psychotherapist specializing in OCD and related disorders at The OCD and Anxiety Center of Greater Baltimore.
References
Chambless, D.L., Caputo, G.C., Bright, P., & Gallagher, R. (1984). Assessment of fear of fear in agoraphobics: the body sensations questionnaire and the agoraphobic cognitions questionnaire. Journal of Consulting and Clinical Psychology, 52(6),1090-1097.
Clark, D.M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24(4), 461-470.
Clark D.M. et al. (1988) Tests of a Cognitive Theory of Panic. In: Hand I., Wittchen HU. (eds) Panic and Phobias 2. Springer, Berlin, Heidelberg
McNally, R.J., & Lorenz, M. (1987). Anxiety sensitivity in agoraphobics. Journal of Behavior Therapy and Experimental Psychiatry, 18(1), 3-11.
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May 1, 2019
Body Dysmorphic Disorder: Part One
It will take courage and maybe a leap of faith to seek help, but you can wake up from the nightmare of living with BDD and learn to change the way you relate to your physical appearance.
Recently I stayed at a hotel for a conference and was delighted to see they had a fancy makeup mirror which I had never come across before. The next morning, I decided to make good use of the magnified side of the makeup mirror for more precise makeup application; however, I was immediately assaulted by what could be described as a multitude of unsightly spots, pores, patchy areas, lines and a host of other imperfections that I had formerly not noticed but was now acutely aware of. While this experience ended rather quickly for me it made me think of the clients I have worked with who described with agonizing detail the inescapable torment they experienced when looking in the mirror. These individuals were suffering from Body Dysmorphic Disorder (BDD).
In this blog series, I will be exploring Body Dysmorphic Disorder which is characterized by obsessive thoughts about perceived defects in appearance which lead to compulsive behaviors aimed at fixing, checking, hiding or camouflaging them. This first entry in the series will focus on defining and exploring manifestations of BDD as well as challenges in diagnosing and treating this frequently misunderstood disorder. While BDD was once believed to be rare, it affects approximately 2 percent of the population. However, it often goes undiagnosed for many years due to lack of knowledge about the disorder in the mental health community and the number of cases that go unreported.
Why would someone suffering so much avoid asking for help?
The profound suffering that people with BDD experience is difficult to articulate. People living with BDD may feel demoralized by the overwhelming self-critical thoughts and time-consuming rituals that can dominate every aspect of their lives. Work, relationships, hobbies and social activities seem to become lower and lower priorities while the drive to cater to the BDD comes first. Despite their best efforts, they are unable to stop the endless rituals, which in turn leads to intense self-criticism and self-loathing that further fuels the sense of inadequacy, the distorted body image, co-morbid depression and sometimes severe suicidal ideation.
People who suffer from BDD often keep their suffering a secret for multiple reasons. Many people who experience BDD feel a deep sense of shame and embarrassment about their preoccupation with their appearance and are afraid of being accused of vanity or narcissism. In addition, they may fear that others are lying to them about their appearance or that they are not being taken seriously. Often times, people with BDD firmly believe that their problem is an appearance problem (as opposed to a mental health issue) so they first seek “help” through cosmetic or even surgical means which reinforces their belief that they are hideously ugly or deformed.
Common Manifestations of BDD
Below is a short-list of the more common areas of the body that those with BDD may become preoccupied with. However, it is important to note that any aspect of appearance can be a target for BDD.
Skin such as texture, scars, acne, wrinkles and lines
Size or shape of eyes, nose or lips
Symmetry of eyebrows, eyes and ears
Size or shape of thighs, arms, stomach, buttocks, and breasts
Muscle mass (often seen in a variation of BDD called Muscle Dysphoria, which typically affects men)
Hair growth, length and texture
Along with the preoccupation, comes the nasty voice of BDD shouting all the ways the sufferer might be rejected, ostracized or outright humiliated due to their imagined ugliness, leading them to make effort to eradicate, reduce or camouflage the area of concern.
Compulsions in BDD
Like OCD, body dysmorphic disorder is characterized by unwanted intrusive thought (obsessions) and behaviors aimed at reducing distress about those thoughts (compulsions). Compulsions in BDD are behavioral attempts to conceal, examine, fix or get reassurance about the perceived defect. While people with BDD are usually told by many friends and family members that they look fine or that they even look better then fine, the effects of these reassurances are short lived and lead to feeling more isolated and alone. While sometimes the compulsive behaviors are obvious to others, especially in more severe cases, oftentimes they are done in secret.
Here are some common compulsions related to BDD:
Checking mirrors or other reflective surfaces to look at perceived defect
Avoiding mirrors or reflective surfaces to avoid being triggered by appearance
Measuring the size or shape of the concern area to check (e.g. measuring the length of one’s nose or width of thighs)
Avoiding foods that are perceived to worsen appearance via weight gain, bloating, or skin blemishes
Using lights or magnifying glasses to enhance their ability to see the area
Adjusting the lighting in rooms to conceal some aspect of appearance
Reassurance seeking questions about disliked body part
Making repeated negative commentary about one’s appearance to elicit reassurance
Comparing their appearance to others
Adjusting body position while sitting or standing to hide the perceived defect
Concealing disliked body part(s) via wearing makeup, hats or baggy clothes
Repeated visits to dermatologists or plastic surgeons for reassurance and/or having procedures
Skin picking or hair pulling in effort to modify or improve appearance
Avoiding social situations where there may be attention on them and their appearance
Like all compulsions, these behaviors may alleviate the anxiety briefly but ultimately reinforce self-defeating beliefs, intrusive thoughts, and anxiety, which all contribute to an increased sense of isolation and self-hatred.
BDD in Disguise
Another significant challenge to getting appropriate treatment for BDD is that it can masquerade as other disorders, such as OCD, Eating Disorders, Social Phobia, Generalized Anxiety Disorder, and Major Depressive Disorder. While these disorders can and do co-occur, they can also be disguises for BDD.
Examples:
Robert is 27 years old and works as a researcher at a local university. Robert spends much of his time in the laboratory and does not have much of a social life. Robert had a girlfriend briefly in college but has stated he is not interested in dating because he is busy with his work. Robert was hospitalized for a suicide attempt his senior year in college after his girlfriend broke up with him. Robert still lives at home with his parents. and Robert has been in and out of therapy for depression since high school. Robert’s parents are worried about him because he has stopped coming out of his room except to leave for work and he has stopped socializing with friends and family. Robert has BDD with comorbid depression. Robert hates the size and shape of his nose. He believes that his girlfriend in college broke up with him because she was repulsed by his grotesque nose. Since the break up he has tried to camouflage his nose with hats and sunglasses. He has had multiple consultations with plastic surgeons who have disagreed with his assessment of his nose. Robert has become increasingly depressed and now avoids interacting with others, including his family, so others can’t see his perceived defect.
Ella is 20 years old and a junior in college. Ella has always been active and tries to eat healthy. As of late, Ella has started to restrict her diet even more and insists on running 5 miles daily. Ella says she doesn’t want to be fat. Ella states that she is chubby and is just trying to stay on top of her exercise. As of late, Ella has been isolating from friends and no longer wants to spend time with her family. Her family is worried she is depressed and is developing an eating disorder. Ella has BDD disguised as an eating disorder. Jane believes her thighs are fat and refers to herself as “thunder thighs”. She spends hours exercising and dieting hoping to alter the shape of her thighs and to remove all traces of fat. Ella tries to sit in a way that makes her thighs look thinner to her. She often squeezes the skin on her thighs to check if they are getting larger. She spends hours looking at pictures of supermodels, trying to assess how different her legs are from the pictures. She refuses to wear shorts, skirts, leggings or bathing suits.
Loved Ones Can Be Instrumental in Recovery from BDD
If you are reading this as a concerned family member, you may be absolutely baffled by your loved one’s concerns about their appearance and you might find their behavior difficult to understand. You have probably tried countless attempts to reassure them that they look fine, or even better than fine, and are shocked when your attempts to reassure them are met with resistance, mistrust, and even anger. You look at your loved one and can’t imagine how they could see themselves the way they describe because you don’t see anything wrong at all. In fact, it may cause great grief to find out how your loved one sees them self. Because you love them, you do anything and everything in your power to help, but it always seems to strangely backfire.
If your loved one has BDD, it is important for you to remember that what you’re seeing are symptoms of a disorder, not character flaws. It’s not your fault and it may comfort you to know that your loved one can lead a happy healthy life with the right treatment. This treatment will also require you to make some changes in how you respond to their symptoms. Many of the changes may seem counterintuitive and you may worry about how your loved one will respond to these changes. Seeking therapeutic support for yourself may be an important part of the equation. Recognizing that the whole family, not just the BDD sufferer, has been impacted by the disorder and getting treatment that reflects that can go a long way.
Facing Your Fear
If you are reading this from the perspective of wanting to know more about your own unwanted thoughts and feelings about your appearance, getting to the end of this blog is a brave step. Because it takes a lot of courage to share with someone your deepest thoughts and feelings and to acknowledge that you may not be seeing yourself clearly, you have to start by acknowledging this possibility to yourself. You may be apprehensive about treating your symptoms as a mental health issue, and you may believe with every fiber of your being that the problem is your appearance. It may seem as if people are being cruel when they compliment you, because how could they not see what you see? You may have shared with others your concerns only to be met with misguided advice or even to be told that you’re being silly. But you are not being silly, nor are your symptoms indicators of vanity or self-preoccupation. They are symptoms of a treatable mental health condition.
You may feel isolated and alone in your own private nightmare, but you are not alone. There are others who have felt the despair you are experiencing and many of them have gotten better with treatment. It will take courage and maybe a leap of faith to seek help, but you can wake up from the nightmare of living with BDD and learn to change the way you relate to your physical appearance.
In the next installment in this series, I will discuss early stages of treatment for BDD which will include the importance of psychoeducation and motivation-building strategies. This will lay the groundwork for how cognitive behavioral therapy (CBT), exposure and response prevention (ERP), Mindfulness, and some BDD-specific interventions can be employed to liberate yourself from this oppressive condition.
Molly Schiffer, LCPC is a psychotherapist specializing in OCD and related disorders at The OCD and Anxiety Center of Greater Baltimore.
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