“OCD is the biggest liar in the world.  Whenever I come back to it with a piece of evidence, it says I have to do it one more time.  I do it, and it comes back, and says it’s not good enough.” ~ Unknown

 As noted in last week’s column, over the past many months I have had a number of Healthy Mind – Healthy Future readers request that I again run the two-part interview I had late last summer with Jonathan Lukas, MFT, Director of the OCD Treatment Center of Santa Barbara.  Mr. Lukas is not only an expert Cognitive Behavioral Therapist specializing the in the treatment of Obsessive-Compulsive Disorder and anxiety disorders in general, but has also had his own long and arduous journey overcoming the challenges of OCD.

To recap last week’s column, Obsessive-Compulsive Disorder, OCD, is an anxiety disorder characterized by repeated, persistent, unwanted thoughts, images or impulses.  These are known as obsessions and produce uneasiness, fear, worry or apprehension.  These lead to performing repetitive behaviors, known as compulsions, that one feels driven to perform in an attempt to reduce the associated anxiety.  These symptoms can become alienating, time consuming and produce severe emotional distress.  OCD sufferers generally recognize their obsessions and compulsions as unreasonable, and may try to ignore or stop them.  However, these attempts only increase distress and anxiety until ultimately one is ‘compelled’ to perform compulsive acts in an effort to ease their stressful feelings.  Despite their driven efforts, performing these so-called “rituals” provides only temporary relief.  The thoughts of obsessive-compulsive behavior keep returning and leads to even more ritualistic behavior which is the vicious cycle that is obsessive-compulsive disorder. 

Dr. Miller:  How do you go about treating OCD?

Mr. Lukas:  First I make a connection with my client that they might not have experienced before.  They are getting first hand insight into living through some of the worst that OCD has to offer and my journey out of those dark places to find that I have overcome these symptoms with hard work and a willingness to face extremely intense levels of anxiety and to step up to the obsessions and compulsions that have taken so much joy out of their lives.  In short, I work with them through identifying their obsessions and educating my client about what obsessions really are, just false messages that cause a fight or flight response of misinterpretations and over-interpretations of thoughts that manifest because of a brain disorder.

Those with OCD over-interpret, misinterpret, and engage these catastrophic thoughts, and become overwhelmed by these obsessions to the point that they feel helpless.  In response to the anxiety that results from these thoughts, the OCD sufferer engages in compulsive, or ritualized, behaviors to try and cope with the intense thoughts that can be adrenaline inducing and terrifying, and lead to an urge to try and “fix” these thoughts. The person develops highly rigid mental and/or physical rituals that feel necessary to perform but virtually impossible to stop.  Those ritualized behaviors give very short-term relief but actually feed the intensity of the obsessions, causing the person to feel more and more reliant on those compulsions that in the end really feel futile and overwhelming themselves.   I help my clients understand that obsessions are nothing more than random thoughts that every human experiences, but those with OCD get locked into these thoughts whereas a non-OCD brain would likely brush these thoughts off as bothersome but likely nothing more.

For example, a client might be obsessing about crashing his car into oncoming traffic.  These thoughts, once they trigger an anxiety response in the OCD brain, become obsessions because they are so intrusive, intense, graphic, and unwanted.  The thoughts seem to repeat like a skipping record.  The person begins to try to stop the thoughts with attempts to think of a pleasant thought, such as imagining the car arriving safely home.  As this doesn’t work, they engage in physical rituals that might involve tapping the rear view mirror, saying a verbal prayer ritual when driving through an intersection, or coughing as he or she drives by oncoming traffic to drown out the intensity of the thought.  When this still doesn’t work, the person will likely interpret these thoughts as a warning sign that they might be dangerous to other drivers.  They begin to avoid certain areas that they normally drive and even avoid driving altogether.  At this point the obsession has affected their daily functioning and the continued avoidance of driving or even thinking about driving causes significant distress in their life.  The thought, which was initially unsettling, has turned into an adrenaline-inducing obsession that is now causing avoidance and isolation.  If the person has given up driving because of a frightening obsession, they are giving right into the OCD.  The cycle of obsessive thoughts leading to ritualized behaviors and/or avoidance is causing a vicious loop of thought, increased anxiety, reaction to the anxiety, known as ritualized behavior, and this cycle repeats itself more frequently as the obsession is engaged over and over again.

I help them go to battle to face these intrusive thoughts and ritualized behaviors through a specialized form of Cognitive Behavior Therapy called Exposure and Response Prevention.  This is the process of facing these obsessions and compulsions through facing the intrusive thoughts without the need to ritualize [Response Prevention].  The client will actually face the obsession with imaginal exposures such as envisioning the feared event actually taking place.  With repeated imaginal exposures and a new interpretation of these thoughts, the client is able to experience a reduction in the level of anxiety and the frequency of these obsessions. As the client gains more confidence and insight they are then able to work with me on actual exposures such as getting in a car and driving while still focused on the obsession.  As they experience the reality of their thoughts, that they would never actually or intentionally drive into oncoming traffic, the intensity of this obsession and the danger that they once felt begins to feel less real and less bothersome.  This is the process of habituating and actually experiencing your anxiety diminish over time.  With a new understanding of how OCD works in the brain and a dedicated effort to accept anxiety-inducing thoughts as just mental hiccups, my clients are able to experience taking the power and intensity out of the obsessions.  It’s very much like once you stop feeding the obsessions with these behaviors, you are starving them of their power and effectiveness until you can accept these thoughts as nothing more than impulses in the brain.   They are no longer perceived as dangerous.  It really can be a very exciting experience for my clients to actually feel relief for the first time and this only helps to gain confidence over time as we go through each obsession one at a time.

Make no mistake, this is not easy work for the client because it takes a willingness to let go and try to approach their OCD in a new way.  Although OCD is a serious anxiety disorder, with proper treatment including both CBT and possibly medication, for more treatment-resistant OCD, clients often experience a drastic reduction in both obsessions and compulsive behavior.  Therefore it takes patience, setbacks, and even increased anxiety initially to face our most intense obsessions.  But with empathy, true understanding, and occasional disclosure about my own personal struggle, positive changes can take place.  What often comes from this is a new view of life, new hope and improved self-esteem and confidence that begins to play a part in the client beginning to stop isolating and avoiding and “start living.”

Dr. Miller:  How do you view medication for the treatment of OCD versus Cognitive Behavioral Therapy alone?  What would you tell a parent who is concerned about the prospect of their child potentially needing medication for the symptoms of OCD?

Mr. Lukas:  As a Cognitive Behavioral Therapist, my objective is to help my client reduce the severity of obsessive, intrusive thoughts and ritualistic behaviors.  In some cases the intensity of obsessions can be so severe that they interfere dramatically with normal functioning.  For example, when a client is so anxious that they are unable to eat, sleep, and even get out of bed in the morning, therapy alone is often not enough.  With such difficulty in basic functioning because of OCD’s hold on them, medication is necessary to allow the sufferer to gain a foothold on their symptoms by reducing the anxiety enough so that they can nourish themselves, have the ability to sleep, both of which are essential for healthy brain functioning, and give the client some breathing room to begin to face OCD with less intense symptoms.  Without medication it can be very difficult for a client to do the work that is needed because their anxiety is often so crippling that Cognitive Behavior Therapy, including helping a client see that their thoughts are not real, or dangerous.  Medication can allow for some leeway so that I can do the work with them and have them more present in our sessions where I can help them understand their thoughts in a new way.  It is in our sessions where I can help a client resist the need to engage in compulsive behaviors so that they can continue the work at home.  Without medication, such as benzodiazepines and SSRI, SNRI, and even Atypical Antipsychotics for OCD and co-morbid depression/Bipolar, etc., the ability to break though the “mental hiccups” is that much more difficult.

For example, when I was an adolescent, my hypochondriasis was so severe that I was convinced that I was suffering from symptoms related to full-blown AIDS.  I would have anxiety spikes any time I caught a cold, thought I was catching a cold, any time I lost weight from no appetite, or even noticed a blemish or sore on my skin.  These symptoms would send my OCD into “the Red Zone” leaving me checking my temperature over and over, running to the doctor, and even reading about “dying with AIDS” articles that I would find while sitting in a library for 6-8 hours a day.  At this point, I was unable to function and therapy at that point was not enough.  I needed a daily regimen of SSRI (such as Lexapro) and an Anti-Anxiety (such as Klonopin) which allowed me some breathing room to eat, get some sleep, and even get out of bed in the morning, instead of just lying in bed terrified that I was dying, even though there was nothing physically wrong with my immune system, I was locked into the OCD.   With each compulsion (checking temp, feeling my throat, weighing myself, etc.) I was actually giving validity to the obsession that I was dying from this disease.

With medications such as an SSRI and benzodiazepine for anxiety I was able to find some relief from the intensity of the thoughts which allowed me to engage in therapy more effectively.   This does not mean everyone who suffers from OCD needs medication.  Often it depends on the severity of symptoms, the client’s own insight into OCD as a brain disorder and a willingness to face obsessions without ritualizing.  I have worked with people from all age groups who have been able to face OCD without medication but more often than not, medication is necessary because of the amount of time that the client was not being treated which therefore means long periods of time where OCD was really able to grab hold and thus an increase in symptoms over time has led to the severity that justifies medication.

Parents are often concerned about medication because of the long term effects, the fear that their child will become addicted to anti-anxiety medication, and sometimes even their own negative experiences with medication.  I remind them that OCD is a chronic brain disorder.  Like Diabetics who might require insulin, OCD often requires medication to help stabilize and reduce the symptoms so that their child or adolescent can find some relief from the OCD.  I always remind them that it’s their choice but I know from personal experience, medication helped me get to where I am today.  I have managed to contain my symptoms so that they are nothing more than a minor nuisance, an occasional obsession, but never a need to fall back on ritualistic behavior to reduce my anxiety.  If my child were suffering from OCD, I would have no difficulty making the decision to medicate if it meant improving the quality of my child’s life if I knew that the symptoms could not be dramatically helped with CBT alone.  Lastly, these medications can be used for a period of time and in some cases reduced and then stopped altogether.  Some clients of mine find that just having an anti-anxiety medication nearby is enough to help them get through their anxiety without even needing to use it.  Others are thankful that they have found the right medication while working with me to experience new insight into their OCD thoughts and a new ability to stand up to the obsessions and the compulsions.

Dr. Miller:   Mr. Lukas, thank you for your time, and for being so courageously open in sharing your experiences and struggles with OCD.

Jon Lukas, MFT can be reached for a confidential consultation either by phone at (805) 453-2347 or via e-mail at jcl5050@cox.net