The concept "reasonable doubt" may help some better understand OCD

When most people think of Obsessive Compulsive Disorder (OCD), they think of people excessively washing their hands or repeatedly checking their doors and windows to see if they are locked.   But there are many variations of OCD, including a subtype in which people have intrusive, unwanted thoughts about harming spouses, friends, co-workers, strangers, or even their own children. Sometimes called “Harm OCD”, this condition falls under the category of what is commonly called Pure Obsessional OCD, or “Pure O”, because both the obsessions and the compulsions are primarily mental.

People with Harm OCD often perform mental checking rituals just as others with OCD might physically check their stove over and over again in an effort to feel sure that they haven’t accidentally left a burner on.  They might repeatedly monitor and analyze their mental processes in an effort to convince themselves that they will not act on their unwanted thoughts, and that their intrinsic character or their love for the other person is strong enough to prevent them from doing some sort of harmful action.  They may also repeatedly seek to determine whether they are a bad person for even dreaming up such a thought.  And it is quite common for those with harming obsessions to repeatedly ask others for reassurance that they have not harmed someone or that they are not going to do so.  But as anyone with Harm OCD knows, these efforts to gain certainty almost never provide the desired reassurance for the OCD sufferer, and the unwanted thoughts almost always increase in frequency and intensity.

Through my years of working with those with OCD, I cannot tell you how many times I have heard the names Andrea Yates and Susan Smith brought up in therapy. Numerous times I have been asked by a client suffering with Harm OCD, “Is it possible that I will go crazy and kill my child like that woman in Texas”? Now, we can add one more name to the list of infamous women accused of killing their own children – Casey Anthony.

I was so shocked by the verdict this past summer in the Casey Anthony trial. Ms. Anthony was charged with murdering her two-year-old daughter Caylee, and from reading news reports, the evidence presented at trial seemed to support a conviction.  Yet in July, a jury of her peers found that there was “reasonable doubt” about Casey Anthony’s culpability in the death of her daughter. Now Ms. Anthony is a free woman, having been found not guilty of murder, despite the fact that: a) she did not report her child missing for 31 days; b) she was convicted on charges of lying to the police numerous times about her whereabouts around the time of her daughter’s disappearance; c) her child’s skeletal remains were found in a swampy area with three pieces of duct tape across her mouth; and d) court testimony revealed that around the time Caylee disappeared, Casey Anthony’s car reeked of human decomposition. And while her guilt seems obvious to me and many others, the jury members apparently had enough “reasonable doubt” that they acquitted her of murder.

Recently, I was thinking about what the jury was tasked with during their deliberations. They were given instructions to decide her guilt “beyond a reasonable doubt”. But how does one measure the reasonability of one’s doubt? How much doubt is not enough or too much? What quantity of doubt is just under the threshold of acceptability for which you would send a person to death row? It seems too subjective for such an important decision as convicting someone of murder with the possibility of a death sentence.  And this may have been why the jurors found it easier to err on the side of acquittal rather than conviction.  They may have felt that they needed a smoking gun – a higher level of certainty.

Likewise, the individual with harming obsessions must subjectively decide if his/her doubt is “reasonable” or not. Being a therapist who specializes in treating those with OCD, I can only imagine what an especially difficult task quantifying reasonable doubt would be for many of my clients. People with OCD and related OC Spectrum Disorders such as Body Dysmorphic Disorder (BDD), Hypochondria (Health Anxiety), and Social Anxiety are on a constant quest for answers to unanswerable questions. They seek to quantify that which cannot be quantified, to gain certainty when it is only possible to be “pretty sure.” These are questions that most people who do not have OCD can accept despite their inevitable doubts.  But for many people who experience OCD or a related spectrum condition, “reasonable” doubt often feels unbearable.

Doubt is such an intrinsic part of OCD that the condition has often been referred to as “the doubting disease. Some common doubts seen in OCD and related OC Spectrum Disorders include:

• Are my hands clean enough to ensure that I won’t accidentally make someone sick through casual contact?
• Am I straight enough to to be certain that I am not actually gay?
• How do I know if I really love my spouse?
• What level of pain is a enough that I should visit a doctor to see if I have a serious medical condition?
• What is the right amount of eye contact to avoid being seen as socially inappropriate?
• How do I know whether I am a good person or a bad person?
• If I become angry at my child, does this mean that I do not love them enough, and that I am close to mentally snapping and harming them?

The only realistic answer to these and similar questions is to accept that nobody has 100% certainty on these issues, and to stop the mental checking. The goal is to make decisions based on what is “most likely”, given all the evidence. For people with OCD, it may feel terrifying to make that leap and take that chance because their brain is telling them that absolute certainty is required.

But these questions can become less important if you stop responding to them. Using Cognitive Behavioral Therapy (CBT) and Mindfulness techniques, people with OCD and other anxiety conditions can learn that the best response is to tolerate uncertainty and to observe their thoughts (and the accompanying discomfort) as they rise and fall naturally. In most cases, their worst fears will be disconfirmed without any intervention. Conversely, continuing to respond and react to these distressing thoughts will only lead to an endless cycle of questions and more attempts to find answers. This cycle only serves to reinforce the OCD, and creates the exact opposite from the desired effect – more uncertainty.

•Stacey Kuhl-Wochner, LCSW, is a Licensed Clinical Social Worker at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions.  She can be contacted stacey@ocdla.com.

Jon Hershfield, MA, of the OCD Center of Los Angeles discusses common challenges seen in the treatment of Sexual Orientation OCD, also known as HOCD or Gay OCD.  Part four of a four-part series.

Sexual Orientation OCD - also known as HOCD or Gay OCD - is best treated with Cognitive Behavioral Therapy

In my previous blog on Sexual Orientation OCD (aka HOCD), I looked at some of the potential sub-types that appear in this condition.  While they are all treated with various Cognitive Behavioral Therapy (CBT) strategies, crippling fear can lead people toward beliefs that impede therapy.  Here are some thoughts about treatment issues I commonly hear from HOCD clients.

My Big Gay Secret Self

Many HOCD sufferers, regardless of sub-type, become preoccupied with the idea that other people might think that they somehow “appear” gay.  As a result, some men with HOCD may over-attend to the way they dress, opting for baggy, neutral choices rather than fitting, stylish choices that they might associate with homosexuality.  They may pay special attention to the way they speak or even the way they hold a drink, trying to eradicate any possibility that a person may mistake them for being gay.  Women with HOCD may over-attend to the length of their hair, or whether their clothes are “feminine” enough.  Both men and women with HOCD are likely to obsess about their body type and whether there is something inherently “gay” about it.

Some of this distorted thinking comes from limited or erroneous information they have collected about homosexuals, which leads them to compulsively avoid stereotypes that really have little to do with homosexuality.  Still the HOCD persists with the notion that the sufferer has some clue of what gay “looks like” and then compels them to avoid that.  For most, this appears not to be a fear of negative evaluation, but more a fear that this imagined person who may somehow identify them as gay will actually be seeing into their soul – that if another person calls them gay, this person is seeing their “true self” and this will confirm their worst fear… gay denial!

There is no gay denial.

There is no latent homosexuality, there is no hidden self.  It’s something someone made up one day.  It does not exist.  There is no secret version of yourself waiting to be discovered (yes, I anticipate lots of angry emails from your psychoanalyst).  I think it is important to recognize that people often choose to modify their behaviors to fit with what they think society expects of them.  In some cases this results in people of one sexual preference choosing to live the lifestyle of another sexual preference as a way of avoiding what they see as the negative consequences of accepting themselves as they are.  This could be done in order to avoid professional, cultural, religious, or other consequences.  Of course, there may be a small percentage of the population that somehow is not conscious of what their preferences are, and appear surprised when they “come out” as gay.  I am assuming these people exist because I have seen them on television, but then I see a lot of rare and bizarre things on television.

In all seriousness, there are people who claim not to have known their sexual preference until they met the right person.  This concept is very disturbing to an HOCD sufferer.  Yet it cannot be referred to as “coming out” since it is really more like “waking up.”  And this real “coming out” doesn’t begin with fear, but with yearning

Get Out of the Way

The most effective treatment for all forms of OCD is a type of Cognitive Behavioral Therapy (CBT) called “Exposure with Response Prevention” (ERP).  The most common impediment to ERP treatment for HOCD is the continued practice of compulsive behavior throughout the exposure itself.  Usually this comes in the form of self-reassurance.  For example, many HOCD sufferers may attempt to overcome their fears by exposing to gay pornography, gay neighborhoods, or other things that are likely to trigger their discomfort.  Among the most common self-ERP attempts I hear involves reading online “coming out” stories.  All of these may be good ideas for ERP work, but they can easily backfire for the following reason: trying to prove you don’t like the porn, or that you don’t belong in the gay neighborhood, or that the person in the coming out story is nothing like you will never work.

ERP only works if the person resists doing this mental ritual, and instead accepts whatever thoughts and feelings the OCD may throw at them without protest.  In more intensive ERP, you are not only accepting the thoughts, but actively agreeing with them, diving head first into the fear instead of tip-toeing around it.  Any effort to analyze the exposure for evidence of your sexual orientation results in the brain confirming once again that your sexuality is up for debate.  If instead, your behavior indicates to the brain that the presence of triggering material does not result in mental rituals, then your brain will begin to recalculate its position on the importance of knowing the certainty of your sexual orientation.  In other words, if you stop doing mental compulsions aimed at finding certainty about your sexual orientation, your brain will learn that it is not necessary to have that certainty.

A common fear related to ERP treatment is the distorted idea that accepting the presence of gay thoughts in your mind somehow leads to a likelihood of acting out gay behaviors.  This OCD logic has the sufferer in a double bind in which doing compulsions feels like a way to protect oneself from becoming gay, but at the same time actually fuels the obsession about one’s sexual orientation.  When someone with HOCD stops doing the compulsions, they often see this as dangerously opening the door to unwanted gayness.  This is not unique to sexual orientation OCD, as it is an identical frame for the harm OCD sufferer who worries that accepting harm thoughts will lead to violence, or the contamination OCD sufferer who worries that not washing will lead to contracting a terrible disease.  It is important to remember, then, that ERP for OCD always feels like you are doing something wrong.  This is because what you thought was right (compulsive behavior) is actually the source of the problem.

Feeling Gay

As the ERP work intensifies, the OCD fights for its own survival by leading the sufferer to fear that they are “feeling” gay.  Feeling gay is an interesting phenomenon because it is oxymoronic.  A truly gay person does not over-attend to gay feelings, but sees them as a normal part of their existence.  It’s no more conscious than the feeling of me having brown hair.  A gay person doesn’t sit around “feeling gay” any more than a straight person sits around feeling straight.  It’s the OCD that makes someone over-attend to their feelings, and it’s that same over-attending that distorts these feelings into something to obsess about.  An HOCD sufferer is likely to report feeling gay when they do exposure work and being terrified by this.  But the fact that they report “feeling” gay actually means they don’t have any idea what it is like to actually be gay!

An additional challenge to ERP treatment often presents itself when a person starts to initially see the benefits of the treatment.  At that point, the person habituates to things that would previously have triggered a significant spike in their anxiety.  As this habituation takes place, the person’s thoughts and feelings become more congruent with those of non-HOCD sufferers.  In other words, the individual becomes less upset by the presence of the unwanted thoughts and feelings they experience related to the issue of sexual orientation.  At this juncture, some with HOCD then begin to obsess that they are not “bothered enough” by the trigger, and then use this as evidence of their homosexuality.  This is sometimes referred to as (awkwardly enough) a “backdoor spike” because the OCD goes from identifying the fear as evidence of being gay, to now identifying the lack of fear as evidence of being gay.

What often goes unnoticed in HOCD and similar obsessions is that demonstrations of disgust and terror can also be compulsions, which are essentially behavioral strategies for avoiding or reducing discomfort.  This does not mean they always feel good to do (often they do not).  By actively causing oneself to be repulsed by gay thoughts, a sufferer can then avoid the discomfort that comes from thinking that the gay thoughts are acceptable and then inferring that this makes them gay.  It’s enough to make anyone dizzy.

Whether the OCD is using fear or ambivalence as its threat, the goal of treatment needs to remain firmly focused on accepting whatever is going on inside as simply going on.  Thoughts happen, feelings happen, sensations happen, and nowhere in this does anyone have certainty as to what it means.  We guess and we tolerate whatever discomfort we imagine could come from being wrong.  Life without OCD is lived in the present, making choices based on current preferences, not predictions, and choosing labels based on patterns in those preferences.

The Fear of Not Having HOCD

One of OCD’s more sinister sneak attacks is the threat that having HOCD is just a cover for not accepting that you’re gay.  Of course, sufferers of all types of OCD obsess about not having OCD.  The “scrupulosity” OCD sufferer may see OCD as a way of denying they are sinners, while a “contamination” OCD sufferer may debate whether they are just inherently lazy about cleanliness, while someone who obsesses that they might be a pedophile or a murderer will worry that identifying their problem as being OCD is just a way to avoid accusations of being a monster.

All of these people miss the larger point, which is that non-OCD sufferers do not obsess about having OCD.  To be clear, virtually everyone has some obsessions and compulsions, but roughly 2-3% of the population has them to such an extent that it impairs functioning and is diagnosable as a disorder.  So a non-OCD sufferer may be disturbed by an intrusive thought or may engage in a pointless ritual, but they do not get so completely trapped by this cycle that their quality of life is affected, and they are unlikely to be concerned with whether or not they have OCD.

HOCD sufferers often seek reassurance from their treatment providers that they do indeed have OCD.  This is really the same reassurance-seeking compulsion that they engage in elsewhere when trying to gain certainty that they are not gay.  Just as the HOCD sufferer must learn to tolerate uncertainty related to their orientation, they must also learn to tolerate uncertainty related to their diagnosis.  If somehow they managed to be in such denial that they convinced an OCD specialist to diagnose them with a disorder they didn’t have, then they must have been obsessing over that denial to such an extent that they compulsively sought reassurance from a treatment provider who would tell them they weren’t gay.  That sounds like OCD to me.

Gay Fantasy and OCD

Some people have gay sexual fantasies.  Some people have OCD.  Some people have both and none of this has to do with one’s sexual orientation.

Sexual fantasy in itself is a healthy thing.  While there are ways in which it can be used compulsively or destructively, for the most part mindfully observing arousal thoughts is an activity we should all be able to enjoy as one of the perks of having a brain.  Most, if not all, sexual fantasy involves taboo.  It is this state of actually allowing ourselves to entertain and fully embrace and accept “wrong” thoughts that is so stimulating and freeing.  It is good because it is oh so bad.  For example, a heterosexual man may conjure up in his mind the fantasy of cheating on his wife.  This man is not necessarily interested in cheating on his wife and in all likelihood he would run awkwardly away from an opportunity to actually do so.  If he walked into a room and a beautiful stranger were laying there saying “take me,” he would probably not be comfortable.  “This is a real person,” he thinks, “someone’s sister or daughter!  Plus, are they disease free?  When was the last time they showered?  What will they think of me afterwards?  What will I think of myself?  Will my wife find out?  Would this hurt my wife?  Will I be able to live with the guilt?”  He can accept the fantasy, but not the reality, because the fantasy appears wrong and the reality to him actually is wrong.  The appearance is exciting, the reality is distressing.

For many heterosexuals, gay fantasies are not technically unwanted thoughts themselves.  They are taboo, and while the reality might be unpleasant, the fantasy is undoubtedly stimulating.  But a gay fantasy should not to be confused with an HOCD obsession, which is an intrusive, unwanted thought about the fear of being gay.  For people with actual gay fantasies who also have HOCD, the obsession is not about the existence of the gay thoughts, but about the fear that enjoying their fantasy element means they are engaging in the reality of it.

This is very painful for heterosexual men who, to put it lightly, simply have a dick thing.  They are attracted to women, choose women for their relationships, but simply happen to find masculinity, and penises in particular, to be conceptually activating.  Maybe a penis is a narcissistic reminder of one’s own beauty, or maybe it represents control, power, submission, any number of things.  Maybe it represents freedom from having to always perform as the archetypal strongman in control.  Who knows.  In any case, it is not important.  What is important is to live in the present and allow yourself to value the things that are presently in your life.  If that means today you love being with your wife, but tomorrow you will spontaneously choose to be with a man, then deal with tomorrow when tomorrow comes.  Across all forms of OCD, the energy spent trying to sort out a thought in order to preempt it from creating a catastrophic future is nothing more than a mental compulsion.

Some may note that there appears to be slightly more acceptance of lesbian fantasizing in Western culture and media (note I said fantasizing, not necessarily practicing).  This may be because our patriarchal society promotes the fantasy of men with multiple women to pleasure them, so thinking of them pleasuring each other creates the implication that a man would be happily welcomed to join them.  It’s a chauvinist cultural flaw, but it exists nonetheless.  But women with HOCD tend not to allow this patriarchal loophole to give themselves permission to enjoy gay fantasy.  The OCD mind distorts the pleasurable thought into one being grotesque, sexless, and unlovable.  So the challenge of living with HOCD is both easier and harder as a woman because this perceived acceptance for straight women having gay fantasies can equate to a greater fear that being gay is a tangible truth.

All this being said, it is normal and healthy for straight people to sometimes have gay thoughts.  Whether or not these thoughts are enjoyed or hated is somewhat beside the point.  As a therapist specializing in Cognitive Behavioral Therapy, some beliefs will always seem inherently distorted to me.  The belief that simply having a gay thought and liking it makes you a gay person is one of these beliefs.  Remember, our lives are defined not by the content of our thoughts, but by the behaviors we seek when responding to them.

To read part one in our series of articles on HOCD, click here.

To read part two in our series of articles on HOCD, click here.

To read part three in our series of articles on HOCD, click here.

•Jon Hershfield, MA, is a psychotherapist at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions.  Jon can be contacted at jon@ocdla.com.

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Orthorexia – The Not-So-Healthy Obsession with “Healthy” Eating

Individuals suffering with Orthorexia exhibit symptoms similar to those of OCD and Eating Disorders.

Orthorexia Nervosa (also simply known as Orthorexia) is a relatively new term within the psychological and medical fields. Simply defined, Orthorexia is an eating disorder in which an individual has an excessive and ultimately unhealthy obsession about maintaining a diet that is totally “healthy” and “pure”. Because of their extremely restrictive eating, individuals with Orthorexia are often severely underweight, and frequently lack the proper nourishment to perform basic daily activities. Like most cases involving an eating disorder, the outcome of Orthorexia can be severe malnutrition and a significant reduction of one’s quality of life.

Orthorexia has not yet been accepted as a formal diagnosis by the psychiatric community, and has not been defined within the Diagnostic and Statistical Manual (DSM-IV). However, since first being described by Dr. Steven Bratman in 1996, many health professionals have observed the often debilitating results of this condition.

Symptoms of Orthorexia

Like Obsessive Compulsive Disorder, Orthorexia can be conceptualized as a constellation of obsessive thoughts and compulsive behaviors. The most prominent obsession seen in Orthorexia is an excessive concern about the healthfulness of food. Those with Orthorexia often spend many hours of the day planning and obsessing about what foods they have eaten or will eat, the nutritional content of that food, and how that food has been grown, processed, and/or prepared. Individuals with Orthorexia may obsess about any number of nutritional aspects of food, including, but not limited to the following:

• Calories
• Sugar (especially “refined” sugar)
• High fructose corn syrup
• Fat
• Hydrogenated or partially hydrogenated fat (trans fats)
• Protein
• Carbohydrates
• Glycemic index
• Salt / sodium
• Fiber
• Gluten
• Dairy products
• Fatty acids
• Vitamin and mineral content of the food
• Whether or not a food is “whole” or “organic”
• Whether or not a food is sufficiently vegan, vegetarian, or macrobiotic
• Whether or not a food is genetically modified

The most obvious behavioral symptom of Orthorexia is the compulsive avoidance of foods that the sufferer deems unhealthy or impure.  Individuals with Orthorexia may at first simply eliminate a few specific foods from their diet, but over time, their diets often become more and more restrictive. Eventually, they may eat only a select small number of foods that have been prepared in a manner that they have decided is “correct” or “pure”. At the same time, they may also purchase many expensive, “natural” or “organic” health food products and supplements that they perceive as more pure and/or healthy than traditional foods.

In addition to food avoidance, individuals with Orthorexia will often spend excessive amounts of time researching food issues related to the above concerns. This research may include many hours of internet searching, buying and reading an excessive amount of food, health, and nutrition related books, and near-constant examination of food labels when shopping for groceries at the market.

For individuals with Orthorexia, the obsessive concern with what goes into their bodies may also extend to other, non-food related health issues. Often, they have a disproportionate level of fear related to the possibility of exposure to what they perceive as pathogens in everyday products and in the environment. This may result in compulsive avoidance of certain soaps, shampoos, perfumes, and deodorants, as well as x-rays, vaccinations, or even mercury in dental fillings. They may broadly reject much of western medical science in favor of homeopathy, osteopathy, and other “complementary” and “alternative medicine” approaches.

It is also common for those with Orthorexia to spend much of their social time discussing food, and attempting to convince others of the “correct” way to eat. This may result in conflict with families and friends who do not agree with their views, and who take offense when the person with Orthorexia repeatedly criticizes their food choices. Likewise, those with Orthorexia may take offense when friends and family express their concerns about the health and dietary choices of the sufferer.

On a more internal, psychological level, those suffering with Orthorexia often experience significant guilt and shame when they do not maintain their purist dietary rules. They are usually extremely strict with themselves about their diet and their overall health, and are often overly judgmental towards themselves and their ability to control what they eat. Frequently, much of their self-esteem and sense of identity is rooted in their diet and in their success in satisfying their high levels of self-discipline.

Diagnosis and Relationship to Obsessive-Compulsive Disorder

While some see Orthorexia as an eating disorder, many mental health experts agree that it is best conceptualized as a hybrid of an eating disorder and Obsessive Compulsive Disorder (OCD). Like OCD, Orthorexia is defined by the individual’s obsessive thoughts (in this case, thoughts about certain foods being dangerously unhealthy), and the compulsive behaviors done in an effort to minimize the anxiety caused by those obsessive thoughts (in this case, food avoidance, as well as the other behaviors noted above).

The food avoidance seen in Orthorexia also has an obvious relationship to Anorexia. In fact, many with Orthorexia are eventually diagnosed with Anorexia as a result of weight loss related to their food avoidance. And some mental health clinicians see Orthorexia as a behavioral symptom of Anorexia in which the individual uses the issue of “healthfulness” as a justification for not eating.

It is also worth noting that some with Orthorexia will resort to purging behaviors similar to those seen in Bulimia in an effort to rid their bodies of impurities that they believe they may have ingested. Purging behaviors may include vomiting, use of laxatives and emetics, and use of colon cleansers to rid themselves of alleged toxins. Likewise, similar to those with Anorexia and Bulimia, individuals with Orthorexia often perform other compensatory behaviors such as compulsive exercising in an effort to make their bodies as perfect and pure as possible.

Symptoms of Orthorexia also overlap with those of other Obsessive Compulsive Spectrum Disorders. The excessive focus on “healthfulness” leads many to develop a distorted over-concern with their actual health, not unlike those with Hypochondria (also known as Health Anxiety). Likewise, many with Orthorexia have a distorted body image, much like those with Body Dysmorphic Disorder (BDD).

Because of the extreme restrictions commonly seen in this condition, it is often very difficult for those with Orthorexia to eat socially, or even be in social places at all. As result of trying to avoid being confronted about their food obsession, many with Orthorexia develop a pattern of social avoidance similar to that of Social Anxiety. The result is often a reduction in social interaction, and in some cases, a complete severing of friendships and relationships in order to maintain and protect their diet.

Finally, it is worth noting the overlap between phobias and Orthorexia. The two primary distinguishing features of phobias are the sufferer’s irrational fear of a specific object or event, and their subsequent efforts to avoid exposure to that object or event. Some conceptualize Orthorexia as essentially being a food phobia, in which the individual is terrified of being exposed to foods that they irrationally see as imminent threats to their well-being.

Click here to read part two of this series, which examines the treatment of Orthorexia utilizing Cognitive Behavioral Therapy, a.

•Kimberley Quinlan, MA, is a psychotherapist at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions, including Orthorexia.  She can be contacted kimberley@ocdla.com.

Thought suppression is a common feature of OCD, especially for those with Pure Obsessional OCD (sometimes called "Pure O")

Over the last few weeks, I have had a secret. For most people, this secret would not have been seen as important, but to me it was. Every time I had these thoughts I became overwhelmed with anxiety, fear and an almost palpable sense of terror. As soon as the thought of this secret flashed through my mind, I would have visions that would take me to its worst-case outcome.  As I played these thoughts out in my head, I physically experienced extreme anxiety, as if the discovery of my secret was actually happening.

Just a few days ago, I was on the treadmill and the thought flashed through my mind again. I was immediately plagued with heightened anxiety. Even the lady on the treadmill next to me noticed and commented that my face had a strange look on it. In response to the thought, I did what most people would do. I tried not to think about it.

At that point, I started a conversation with the lady next to me…and the thought popped up in my head. After the conversation was over, I read a trashy magazine… and the thought popped up in my head again. I then began running as fast as I could, dripping with sweat and breathing deeply, and the thought still managed to surface. Actually, not only did it surface, but it continued to inflate in my head, as if it was going to soon explode.

I got off the treadmill, and it was only then that I realized what I had been doing. I was trying to suppress an unwanted, intrusive, anxiety provoking thought. Even though I discuss this concept daily with my clients who suffer with Obsessive Compulsive Disorder (OCD) and anxiety, I had forgotten it for myself, and had spent over an hour trying to push away these scary thoughts instead of embracing them.

OCD and Clinical Studies on Thought Suppression

Thought suppression is a common feature seen in OCD, especially for those who suffer with what is sometimes called Pure Obsessional OCD, or “Pure O”.  But nobody wants to have anxiety provoking thoughts.  When we experience unwanted, distressing thoughts, we quite naturally respond by trying to control them, ignore them, or push them away. Unfortunately, many clinical studies have proven that trying to suppress unwanted thoughts usually results in the person experiencing the thoughts more often and in a more intense way. That was definitely the case for me.

The concept of “thought suppression” was first studied by Wegner, Schneider, Carter, and White in 1987.  In this study, a group of people were asked to not think about (or to suppress thoughts of) white bears for 5 minutes. During this time, participants were asked to verbalize their thoughts and ring a bell each time they thought about a white bear.  Following this initial 5-minute period, participants were then asked to purposely think about white bears for another 5-minute time period.  The results showed that participants reported thinking about white bears almost twice as often in the 5-minute period during which they were asked to not think about white bears.

If you suffer with intrusive thoughts, you may ask “Why doesn’t this happen with all of my thoughts?  Why is it that I always remember and I am always plagued by these intrusive thoughts, yet I can forget many of the items on my grocery list?”  The answer is simple - the items on your grocery list are not anxiety provoking, and you are not trying to forget them. The problem with trying to suppress unwanted, anxiety provoking thoughts is that the more effort you put into forgetting these thoughts, the more likely you are to be unable to forget them.

Treating Intrusive OCD Thoughts

So, if you have ever experienced the angst of unwanted, intrusive thoughts…or if you are curious about my secret, you might be wondering “How can I get those horrible thoughts out of my head?” or “How did she get those thoughts to go away?”.

The most effective approach to take in managing intrusive, unwanted thoughts is Cognitive Behavioral Therapy (CBT).  And the most basic tool in CBT is what is commonly known as Cognitive Restructuring, in which a person with an unwanted thought briefly and objectively reviews the thought.  For example, when I stopped to look at my secret thought, I immediately realized that it was neither rational nor realistic.  I identified it as such, and assigned it an alternative thought that I could use to challenge the thought when it next arose.

Unfortunately, for those with OCD, Cognitive Restructuring can quickly become a compulsion in itself.  We have treated many people who are unable to get the benefits of Cognitive Restructuring because they quickly resort to compulsively analyzing their thoughts (and the alternative thoughts they come up with to challenge their unwanted thoughts) in an attempt to control them.

For this reason, a different approach is needed.  When faced with intrusive, unwanted, anxiety provoking thoughts, the most effective long-term cognitive tool is what is commonly called “mindfulness”.   From a mindfulness perspective, when one experiences intrusive, unwanted, anxiety provoking thoughts, the goal is not to attempt to reject them or or push them away, but rather to allow and accept their presence in your mind – to have a more open and peaceful relationship with them.  This doesn’t mean that you need to enjoy the thoughts or accept the legitimacy of their content.  It merely means that you accept reality as it is…and reality is that these thoughts are in your head.  Think of it as being similar to accepting a rainy day when you had planned to go to the beach – you may not like the rain, but you will be a lot happier accepting it and getting on with your day than you will be if you get angry at the rain for existing.

The most important component in managing unwanted thoughts is changing one’s behavioral response to these thoughts.  People with OCD often try to control and/or avoid their anxiety-provoking thoughts.  Unfortunately, as noted above, this only results in having more of the same thoughts.

While it may seem counter-intuitive, the most effective behavioral response to unwanted thoughts is to allow them to exist while making no effort whatsoever to control or change them.  In fact, if you really want to  challenge  these thoughts, the best approach is to purposely choose to have them.  If you do this, you will soon discover that you have de-fanged these thoughts.  You may still have these thoughts – after all, many people, including those without OCD have similar thoughts – but you will care far less about them.  They are, after all, just thoughts

So how did I deal with my “secret”?  Using the above techniques, I accepted that the thought was not that important and that it did not require such a heightened and lengthy response. I accepted that this thought is no more important than most of the thoughts I have on any given day, such as “what color shirt shall I wear” or “what will I have for lunch” or “should I  shower before or after dinner”.  The most important thing to remember is that suppressing the thought will only make it stronger. Avoidance will almost certainly not make the thought go away.

I am assuming the fact that you have read this far means that either a) you have experienced the distress and aggravation of failed attempts to use thought suppression, or b) you are still waiting to learn what my secret was.  If you are among the first group and are experiencing unwanted thoughts, please don’t hesitate to contact us so we can help you learn the tools to manage your intrusive thoughts. And if you are among the latter group and are still hanging on to hear the juiciness of my secret, read the last paragraph again – the secret and the thoughts were not important!

•Kimberley Quinlan, MA, is a psychotherapist at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions.  She can be contacted kimberley@ocdla.com.

Jon Hershfield of the OCD Center of Los Angeles discusses treatment of Sexual Orientation OCD, also known as HOCD or Gay OCD, using Cognitive Behavioral Therapy (CBT) and Mindfulness.  Part three of an ongoing series.

There are many variations and sub-types of Sexual Orientation OCD (HOCD)

When I initially wrote the part one and part two of my article on Sexual Orientation OCD (aka “Homosexual OCD”, aka “HOCD”, aka “Gay OCD”), it was intended solely to reflect this rather common form of the disorder as I saw it presented in several of my clients.  I had not anticipated such a significant online response, with so many additional questions and angles on the subject.

Sexual obsessions in general are under-reported because of shameful feelings associated with them.  And yet there is probably a somewhat higher prevalence of sexual obsessions in OCD than any other obsession for this same reason – the thoughts are unwanted! This seems so very evident in Sexual Orientation OCD because the feared consequence appears so tangible.  In other common OCD obsessions, such as “Harm OCD”, the idea that someone might be in denial of violent impulses is plenty terrifying.  However, there is an understanding that being violent is unacceptable in and of itself.  With Sexual Orientation OCD, the sufferer generally does not see anything wrong with being gay per se, as long as it is not themselves being gay.  This causes a lot of confusion and a lot of resistance to seeking treatment.

I’d like to use this latest installment in what has become a series of discussions on Sexual Orientation OCD to be more specific about the different ways I have seen this OCD manifestation present and the different Cognitive Behavioral Therapy (CBT) strategies that appear to work.  I have attempted to categorize them, but it’s important to remember that sufferers are likely to fall into a combination of several categories and not just one.  Also bear in mind that I will continue to use “gay” or “homosexual” to be synonymous with alternative orientations for simplicity’s sake only.  Homosexual and bisexual individuals with OCD can, and do, sometimes obsess about being straight.

All-Or-Nothing HOCD

This is perhaps both the most common and the least reported subtype of HOCD because it is easy to overlook the OCD characteristics.  In short, All-Or-Nothing HOCD describes the experience of those who have always been of one orientation, have never experimented with other orientations, and who do not have gay fantasies, but who just randomly have a “gay” thought or feeling one day and it scares them.  It is often reported as starting with a simple, “Did I find that person attractive?” and “What does it mean that I can’t be 100% certain that I did not find that person attractive?”

In All-Or-Nothing HOCD, the primary distorted belief is that straight people never have any gay thoughts, so any gay thoughts must be an indicator of latent homosexuality.  In fact straight people do have gay thoughts, but generally prefer not to apply them to gay sexual behaviors.  In actuality, it is not possible to know what the word “gay” even means on a literal level without having what can only be described as a “gay” thought.

So for the sufferer who sees gay thoughts as contaminating an otherwise purely straight mind, compulsions are going to be focused on making the gay thoughts go away through various proving rituals.  This may take the form of compulsive masturbation to straight fantasies or avoidance of anything that might trigger the presence of a gay thought.  It often involves avoiding people who the sufferer sees as even having the potential to be gay.  Just as a handwasher tries to be certain there is not contaminant on their hands, this HOCD sufferer is aiming for total eradication of the unapproved gay thought.

Cognitive Behavioral Therapy (CBT) treatment strategies for All-Or-Nothing HOCD should involve gradual exposure to things that trigger gay thoughts while the sufferer practices resisting the urge to tell themselves they are not gay.

Relationship HOCD

People are complicated.  That means relationships are twice as complicated.  Some people are lucky in love, some people are unlucky, some people are both, and some people really can’t tell because of their OCD.  This form of  HOCD occurs when an OCD sufferer uses potential gayness as an explanation for what they see as failed heterosexual relationships.  Women with Relationship HOCD may identify themselves as “man-hating dykes”, while men may see themselves as “just not understanding women”, and may describe themselves as being “in denial” of their “true” sexual orientation.

Often in cases like these, the HOCD itself is a smokescreen for what is sometimes called Relationship OCD (aka ROCD) or Relationship Substantiation OCD.  Those with ROCD tend to have obsessions that revolve around fears of not “really” loving or being sexually attracted to their spouse or partner, not being involved with the right person, or not being the right person for their partner.  Those with Relationship HOCD can put off dealing with these issues if they conceptualize themselves as being incapable of having a healthy heterosexual relationship because, in their mind, they might actually be gay!

Because this form of HOCD emphasizes partnership, sufferers are likely to over-attend to how they relate to people of the same sex.  A man may notice that he feels better understood, has more in common with, and enjoys his time with another man in ways that women do not satisfy him.  The only thing missing is the sex, he thinks, and this triggers a lot of compulsive analysis about who he is “really” wired to love.

Similarly, a woman may become aware that other women share qualities their male partners seem to lack – for example, sensitivity, patience, and emotional availability.  In those who don’t have HOCD, this same-sex identification is looked at as totally normal.  “Of course my same-sex friends understand where I’m coming from.  They know what the other sex is like!  They get my interests and motivations!”.  The word “gay” doesn’t enter into the equation.

CBT for Relationship HOCD is going to involve traditional Exposure and Response Prevention (ERP) for sexual orientation fears, but also exposure to behaviors that demonstrate vulnerability to a romantic partner, accepting uncertainty about the “quality” or “completeness” of heterosexual relationships, and other non-avoidance exposures.

Self-Hating HOCD

This form of HOCD generally has more to do with depression than sex or sexual orientation.  Typically (though not exclusively) this seems to occur in people who were severely mistreated, abused, or bullied.  Just as this can occur in Social Anxiety Disorder, the “bully” takes up residence in the person’s mind and any perceived failure in life triggers an internal statement of “You’re gay.”  It’s meant as an insult, more than a suggestion that one should set about finding themselves sexually.

The constant inner-abuse seen in this type of HOCD often leads to a deeper depression, which further distorts the intrusive thoughts, which in turn leads to even more depression.  In some cases this may lead to a pseudo-gay fantasy state in which the sufferer imagines themselves living out what they see as the greatest disappointment to their parents.  The line of thinking is that they are so unlovable as to be invisible to their desired orientation.  In treating those with this type of HOCD, there may be more emphasis on cognitive restructuring and learning to identify “bully” thoughts as distorted glitches in the mind which are essentially irrelevant to sexuality.  Because ERP requires significant motivation and commitment, it may also be clinically appropriate to focus on the depression first before engaging in exposures.

Experimental History HOCD

Despite the fact that same-sex exploration is common in children who are learning about the human body (i.e. playing “doctor”) and discovering how different things look and feel, people with OCD who obsess about their sexual orientation may use benign childhood experiences as “proof” of latent homosexuality.  So despite a post-pubescent life of heterosexual behavior, the presence of unwanted homosexual thoughts triggers frightening doubts.  The sufferer is likely to compulsively review childhood memories and the unknowable memories of thoughts and feelings that might have been had during any same-sex exploration.  “What exactly did I do and why?”

It is also common for teenagers throughout the course of puberty to experience confusion related to gender, orientation, and other sexual issues.  As the sexual brain develops, so too the does the sexual mind.  For people with OCD during their teens, this can be very troubling.  For those whose HOCD develops later, they may look back on this period in which their sexuality was developing and compulsively analyze anything that could be construed as inconsistent with their current sexual preference.

Another variation on this reflecting form of HOCD is compulsive analysis of any same-sex play that might have taken place in college or at some other point in life.  A big part of treatment for those with this type of HOCD is identifying mental checking as a compulsion to be resisted, instead of as a way to figure out one’s sexuality.  Curiosity is not orientation.  Whatever happened, happened.

Real Man / Real Woman HOCD

People who suffer from this form of OCD place a lot of emphasis on masculinity and femininity and the cultural expectations that come with them.  A male sufferer might notice an attractive male, and then chastise himself for being able to notice attractiveness in males.  He assumes this is a sign of femininity, something a “real man” would have no ounce of (again see the all-or-nothing thinking).  This can also present itself through a man’s affinity for the arts or other things he may have been culturally primed to see as non-masculine.

Cognitive Behavioral Therapy (CBT) for this form of HOCD may involve more exposure to material that the sufferer sees as “dainty” or weak, such as watching program with a flamboyant homosexual character or attending a ballet.  This is sometimes more triggering than exposure to gay pornography.

Similarly, a heterosexual woman may notice another woman is beautiful and then distort this through the belief that “real women” only ever think about men.  It also may involve avoidance of assertive behavior or any other cultural attribute traditionally associated with masculinity.  Exposure for this sufferer may involve images and films involving “butch” lesbians or feminist literature.

Groinal Response HOCD

The functioning paradigm here is, “I must experience sexual arousal or groinal sensations only in very specific pre-approved circumstances.”  These circumstances typically mean in the presence of an attractive, age-appropriate member of the opposite sex.  But there are a few important considerations to note here:

• all sexual thoughts (wanted or unwanted) may cause sexual arousal;
• attending to one’s groin actually causes sensations to occur there;
• there are sensations going on in your groin all the time, but unless you go out of your way to pay attention to them, you just don’t notice them;
• groinal sensations often occur for no reason.

Men don’t get headaches just because they thought of something painful and they don’t get erections just because they are feeling sexual.  In short, who knows what’s going on down there?  Yet the HOCD sufferer is going to compulsively check and analyze sensations for evidence of homosexuality.  Part of the confusion the OCD capitalizes on is the fact that groinal stimulation is generally considered a positive sensation.  Fellatio or cunnilingus is going to feel good no matter what gender is delivering it, but the HOCD mind insists it only be delivered by a person to whom we are attracted in order to accept it.  HOCD manipulates the mind into thinking that any positive groinal sensation at the “wrong” time must mean a general sexual preference to whatever is in the environment at that moment.

Cognitive Behavioral Therapy(CBT) for the treatment of this type of HOCD is going to involve identifying and challenging distorted beliefs about groinal responses and exposure to arousing material that falls outside of their traditional preferences.

Spectrum HOCD

Not everyone agrees, but many believe as Alfred Kinsey did, that sexuality exists on a scale with straight on one side, gay on the other, and people mostly somewhere in the middle.  While it will no doubt be triggering for some readers to consider, many people who identify as heterosexual sometimes have homosexual thoughts, feelings, sensations and fantasies.  Those without obsessive-compulsive tendencies allow themselves to enjoy this aspect of their reality.  These are people who prefer sexual activity with the opposite sex, but also find same-sex fantasies (and even behaviors) to be somewhat intriguing and arousing.  They are not bisexuals, who would likely say they are quite capable of sexual and romantic fulfillment with either sex, but are instead heterosexuals who simply are not dangling off either edge of the Kinsey scale.

For those people who experience themselves as somewhere within this spectrum of sexuality, but also have HOCD, this can be very upsetting.  They will want to know for sure if they are bisexual or not, how far in one direction or another they “belong”, and what the “right” term is to describe themselves.  “Am I 10% gay?  20%?  If I don’t know for sure, then I will always feel that I am harboring a secret.”  Without an appropriate label, they live in constant fear of an identity crisis.

Treatment for this type of HOCD relies heavily on Mindfulness Based CBT and resisting compulsive mental analysis.  The exposure is not aimed at homosexuality, but at uncertainty.  This can sometimes be done in the form of an imaginal exposure script in which the sufferer describes the negative consequences of never knowing what to label themselves.

(Really) Need-To-Know HOCD

These are people who identify as heterosexual but have been struggling with untreated (or mistreated) HOCD to such an extent that they have gone from mental checking, to physical checking, to actual experimental checking.  This is somewhat rare and I would imagine some people might read this and say, “OK, let’s just call it gay then,” but that’s not what is happening here.  People who suffer from OCD, regardless of the manifestation, are struggling against an intolerance for uncertainty.  People without OCD largely tolerate uncertainty by not paying much attention to it.

For any reader who does not have OCD, try thinking really hard about the fact that you are not 100% certain what will happen when you die.  Now imagine that all of the people you love will consider you hugely irresponsible for not attaining certainty on the issue.  This is how an OCD sufferer often feels.  Not only do they poorly estimate the risk posed by unwanted thoughts and feelings, but they have an exaggerated sense of responsibility for avoiding these risks.

Ultimately, for some HOCD sufferers, being gay may sound like a relief from not knowing for sure that they are straight.  So they begin to build a case for gayness.  This may involve seeking treatment from LGBT specialists, trying to train themselves to enjoy gay pornography and sometimes engaging in sexual experimentation.  The goal is not necessarily to like gay sex, but to determine once and for all – “am I gay or straight?”.

Typically this backfires in one of two ways.  Either the person finds the experience somewhat satisfactory but not preferential to straight sex, or they find the experience abhorrent and resent themselves for having done it.  In either case, they are left with the same uncertainty they find intolerable, plus more ammunition for the OCD.  Just as in the other forms of HOCD, the objective has to be tolerance for not-knowing rather than proof.

These are the various subtypes and angles on HOCD that I have treated thus far, but there are certainly others.  In the next installment of this series, we will examine some additional nuances to HOCD and common impediments to effective treatment.

To read part one in our series of articles on HOCD, click here.

To read part two in our series of articles on HOCD, click here.

To read part four in our series of articles on HOCD, click here.

•Jon Hershfield, MA, is a psychotherapist at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions.  Jon can be contacted at jon@ocdla.com.

Please note:  the “Comments” section for this article is now closed.

Jon Hershfield of the OCD Center of Los Angeles discusses treatment of Sexual Orientation OCD, also known as HOCD or Gay OCD, using Cognitive Behavioral Therapy (CBT) and Mindfulness.  Part two of an ongoing series.

Treatment of Sexual Orientation OCD

Sexual Orientation OCD can be successfully treated with Cognitive Behavioral Therapy and Mindfulness

As noted in our previous post, Sexual Orientation OCD is a condition in which an individual, straight or gay, obsessively doubts their sexual orientation.  Research has consistently found that the most effective treatment for this and all types of Obsessive Compulsive Disorder (OCD) is Cognitive Behavioral Therapy (CBT), with a focus on Exposure and Response Prevention (ERP).

Over the past ten years, many OCD specialists have also begun to integrate concepts from Mindfulness-Based Cognitive Behavioral Therapy (MBCBT) into their treatment of OCD.  In MBCBT, the goal is to change one’s perspective toward one’s thoughts, as well as the behavioral responses these thoughts lead to.  Using mindfulness, it is possible to circumvent much of the OCD process and ultimately reverse it into remission.

Mindfulness is particularly helpful when treating the more obsessional variants of OCD, including Sexual Orientation OCD.  When combining MBCBT with the traditional tools of Cognitive Behavioral Therapy, the following treatment techniques are used to address the unwanted thoughts and behaviors seen in Sexual Orientation OCD.

Mindfulness – Thoughts are just thoughts.  You have them because you have a brain.  The rest is just details.

Practicing mindfulness means actively observing your own tendency to over-attend, over-value, and over-respond to thoughts.  In Sexual Orientation OCD, the sufferer is over-attending to ego-dystonic thoughts related to sexual identity.  For most people, if they have a thought about a meteor hitting them today, they quickly shrug it off with a “whatever happens, happens” approach.  Anything is possible, and being wrong would mean certain death, but it hasn’t happened so far and life is too short not to go outside just because of the highly unlikely possibility of being struck by a meteor.  But if an individual with Sexual Orientation OCD has a thought of secretly or suddenly being gay, they feel an overwhelming need to investigate, neutralize, and suppress that thought.

When you over-attend to any thought, you automatically give it increased value.  It is no longer a thought that just popped up for no apparent reason; now it is an important thought you carefully monitored until it presented itself!  And now that it has been over-valued, you desperately want to respond to it.  Of course, any response in this situation will be an over-response, because the thought has no important value in the first place.  These unnecessary responses are essentially compulsive efforts to neutralize or eliminate a thought that was meaningless and not worth more than a moment’s attention.  Compulsive behavioral responses in Sexual Orientation OCD typically involve the following:

• Avoidance of sexual orientation-related triggers (i.e. gay people, gay films and TV shows, gay neighborhoods);
• Physical rituals designed to “prove” ones sexuality (i.e. checking ones genitals for signs of arousal, increased sexual activity in an effort to prove to one’s self that they are straight, compulsive masturbation to straight pornography);
• Mental rituals aimed at forcing unwanted gay thoughts away (over-analysis of gay thoughts, trying to force straight thoughts into consciousness, mentally reviewing past sexual encounters, etc.).

Cognitive Restructuring – Thoughts about thoughts that don’t help.

Everyone has distorted thinking at times.  And people with Sexual Orientation OCD have distorted thinking about their sexuality.  In Cognitive Restructuring, the objective is to learn to identify distorted thinking, and challenge it with rational, objective, evidence-base thinking.  Identifying distorted thinking means learning the language of OCD and knowing when to call yourself out on maladaptive cognitions.

This can be a slippery slope for the obsessive-compulsive who may feel inclined to use restructuring as a mental ritual.  The trick is to be straight (no pun intended) and to the point.  A triggering situation occurs, you think something about it, and then you have one shot to modify that thought for something more rational.  It is important to remember that this is not a debate between you and the OCD.  The OCD got its chance to call you gay.  Then you get your chance to challenge the idea.  Anything else is mental ritual.

It is important to understand that mental rituals are compulsions, and that they make your OCD worse.  By spending mental energy trying to prove your sexual orientation, you are only contributing to the brain’s misconception that the thought was important, and that there is some reason to doubt your orientation.  When simple cognitive restructuring is not doing the trick, it is always a wiser choice to return to mindfulness and to accept that many thoughts happen without those thoughts having to mean something important.  Don’t get conned into an OCD contest you can never win.

Cognitive distortions in Sexual Orientation OCD typically include the following:

• All-or-nothing thinking – “If  I have even a single gay thought, that must certainly mean that I am gay.”
• Catastrophizing – “Being gay would destroy my life.”
• Discounting and minimizing the positive – “Despite having had these thoughts many times, I’ve always been straight, but this time is different.”
• Comparison – “I’ll never be happy like that straight couple over there.”

This is, of course, just a sample of the trickery OCD uses with this issue.  Identifying your OCD’s thought traps and mastering the language of CBT for OCD is what you should expect in the early part of treatment.

Exposure and Response Prevention – The greatest change, in fact the only change, occurs when we change our behavior.

We would all like to feel better before actually taking the steps needed to get better.  But that’s putting the cart before the horse, and is not realistic.  We must first change behavior, and then learn patience while we wait for thoughts and feelings to catch up.  Learning to ride a bike requires exposure to the fear of falling, paired with prevention of the instinctual response of jumping off the bike to prevent falling.  Nobody with a fear of falling off a bike gets over that fear before getting on the bike.

Some OCD sufferers may be concerned that this means engaging in homosexual behavior to overcome their fear of being gay.  This is missing the mark.  The fear is not about having gay sex, but is instead about being stuck with thoughts that you think have the power to ruin your enjoyment of heterosexual sex and destroy your life.  So “testing” yourself by engaging in sexual contact outside of your historically-true sexual orientation as a means to overcome this fear will generally backfire.

Instead, a more effective approach would be exposure to thoughts of homosexuality and the fear that you are not who you thought you were.  Your OCD brain tells you that you must not think certain thoughts because they are dangerous to you.  But your rational brain has the power to stand up to this bully and burn out the OCD circuits by intentionally exposing yourself to unwanted thoughts about your sexual orientation.

This often takes a combination of visual, situational, and imaginal exposure.

• Visual exposure would typically involve looking at images or videos of things that trigger the unwanted thoughts while resisting mental rituals to explain or neutralize the thoughts.  To be done effectively, this form of exposure would start with something mildly triggering, such as a picture of an attractive same-sex celebrity.  Once this no longer elicits a fear response, the exposure would be heightened to repeatedly looking at pictures of a more sexual nature, and ultimately multiple viewings of explicit pornographic material.
• Situational exposure would typically involve visiting gay neighborhoods, bars, nightclubs, listening to “gay” music, spending time with gay acquaintances, etc.
• Imaginal exposure would typically involve writing out a short, but explicit story in which you describe yourself living a homosexual lifestyle, and the unwanted consequences that you envision would arise from this.

The objective of these exposures is to intentionally, but gradually, raise the anxiety caused by your unwanted thoughts, and to ultimately demonstrate to your brain that you can tolerate the presence of these thoughts.  Conversely, compulsions teach the opposite – that you cannot tolerate discomfort.  Exposure is the same mechanism employed any time you wish to gain strength.  You lift a weight, something heavier than you normally would lift in your everyday life.  Over time that weight becomes easier to lift.  But the weight stays constant.  What changes is your ability to accept the weight.

On the subject of consequences, it is important to remember that Sexual Orientation OCD causes suffering equal to that of other forms of OCD.  Culturally, the idea of someone worrying about being gay might trigger a sense of amusement in someone not afflicted with this form of OCD.  However, let’s not overlook what the person suffering from Sexual Orientation OCD is really afraid of:

• “My entire history as a lie.”
• “I will be rejected and abandoned by my family and friends.”
• “I will be subject to public ridicule.”
• “I will have to spend the rest of my life having sex that feels alien to who I am.”
• “I will have a lifetime of self-hatred and self-disgust.”
• “I will never truly connect to another person again.”

In short, dying alone in the dark.  Ask the right questions, and every obsessive fear arrives here.  But it’s important to point out that what the OCD sufferer fears is not accurate.  While being part of any cultural minority has unique challenges, I have never heard any genuinely gay clients describe their own homosexuality in the above terms.  Simply put, what the OCD is threatening is not true.

Sexual orientation is so wrapped up in identity that it’s an easy target for OCD.  Obsessive Compulsive Disorder spends its free time researching new and exciting ways to lock you into fear.  There really is no reason to ask why Sexual Orientation OCD happens.  The answer is obvious – because it works.

CBT and MBCBT are aimed at reversing a learned fear cycle.  Your OCD says you must not have gay thoughts.  But gay thoughts exist.  People who say they’ve never had one are lying; not because they are secretly gay, but because it requires a gay thought to even know what the word means.  So if something necessarily exists and you are trying to prevent it from existing, this is not going to work out well.  If instead, you can accept the reality that a variety of sexual thoughts occur as a function of having a brain, then you can train yourself to treat those thoughts with whatever significance that you, not your OCD, deem appropriate.

To read part one in our series of articles on HOCD, click here.

To read part three in our series of articles on HOCD, click here.

To read part four in our series of articles on HOCD, click here.

•Jon Hershfield, MA, is a psychotherapist at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions.  Jon can be contacted at jon@ocdla.com.

Please note: the “Comments” section for this article is now closed.

Many people mistakenly think of Obsessive Compulsive Disorder (OCD) solely as a condition in which people wash their hands excessively or check door locks repeatedly.  There are actually many sub-types of OCD.  In this ongoing series, Jon Hershfield of the OCD Center of Los Angeles discusses Sexual Orientation OCD, also known as HOCD or Gay OCD.

So, Am I Gay or What?

I sat down to write this blog on Sexual Orientation OCD while my wife and I had started to watch a movie (It’s been suggested I work too much).  It’s either irony or personalization, but the opening scene of the movie involves a man kissing his lover… another man.  This is the second film in two weeks that I’ve rented which involve men and their male lovers, something I was not aware of when I selected the films.

Or was I?

Sexual orientation OCD is sometimes referred to as HOCD (an abbreviation for Homosexual Obsessive Compulsive Disorder) or Gay OCD.  This is an unfortunate abbreviation because it misses the true nature of this manifestation of OCD.

Having gay thoughts is not the same as being gay

First, it is not exclusive to heterosexuals.  Over the years, therapists here at OCD Center of Los Angeles have treated many homosexuals (male and female) who are plagued by obsessive fears of being “straight”, and who suffer equally when OCD attacks their sexual identity.  Furthermore, the fears that clients with this condition report have little to do with actually becoming gay (or straight).  At its core, Sexual Orientation OCD is the fear of not knowing for sure, paired with the fear of never being able to have a healthy, loving relationship with a partner to whom one feels genuinely attracted.

Similarly, someone with contamination fears may on the surface appear to be overly concerned with dirt, but this fear is indicative of an overwhelming fear of never feeling clean again.  “If I don’t wash my hands, I will feel this way forever and nothing will be right in the world”. For every cry of “does this mean I’m gay?” there appears to be a louder cry of “does this mean I can’t be heterosexual anymore?”

In my experience with these clients, it also appears to have little to do with homophobia or bigotry.  On the contrary, these clients are often quite open- minded on issues related to sexual orientation.  In fact, it is their own lack of bigotry that often ends up being a fear trigger.  One notable exception is cultural bigotry in which part of their Sexual Orientation OCD is fueled by the broader societal beliefs of the sufferer’s culture of origin.  For simplicity’s sake, I will refer to “gay” throughout the rest of this article to describe any sexual orientation that is not one’s own.  For those who are homosexual but have obsessive fears of “straightness” please substitute the appropriate word.

One thing that has struck me as bizarrely consistent is that OCD sufferers who obsess about their sexual identity seem notably less “gay” than me.  Allow me to illustrate:

• Picture a man who loves the arts, has no interest in sports, admires electronic music, doesn’t “pull chicks” at the bar and feels little discomfort in the presence of naked men in the gym locker room.  Obviously gay, right?  But then, that describes me, despite the fact that I am straight.

• So what is the opposite of me?  A man who loves watching sweaty guys fight over a ball, admires music fronted by long-haired androgynous men singing about love, and showers at home to avoid naked guys… Well, this sounds pretty gay too.

So this is what happens when your OCD locks in on sexual orientation.  Whoever you are, whatever you do, suddenly seems gay.  Just as the selective abstraction found in Contamination OCD makes it appear that dirt is everywhere, so does this same distortion make gayness appear to be hunting you down.

When this form of the OCD is in full swing, sufferers tend to over-attend to any indication that their “sexual orientation of origin” may be compromised.  Since anxiety, distraction, and a lack of being “in the moment” are likely to make sexual experiences less gratifying, this often becomes a major trigger.  “If I don’t always want to have straight sex, I must be gay!” Interestingly, the idea that they might be asexual altogether doesn’t come up.  It’s the fear of the dark side, not the neutral one.  And the idea that their libido is actually compromised as a result of the anxiety and obsessions that they experience due to their OCD just sounds like an excuse, rather than a rational argument.  You simply cannot win when you play OCD’s game – OCD cheats.

Many people who suffer from Sexual Orientation OCD get stuck on the notion that they may or may not find someone attractive and that this may or may not mean something important about them sexually.  If they see a member of the same sex, they feel it is possible that the “seeing” was really intentional “looking” and that this intentional looking indicates a secret sexual desire.  They will often then attend to and monitor their genitalia to check for arousal in an attempt to prove or disprove the theory.  This often backfires since attention causes sensation.  This, by the way, is true of other body parts as well.  When you consider picking something up with your hands, the brain actually sends a priming impulse to the hand before you’ve even made a decision to move.

It is important to recognize the fundamental error in the line of thinking that pairs acknowledgment of attractiveness with sexual desire.  Attraction is a word we use to describe the feeling of being pulled into something, like a magnet.  We generally conceptualize this feeling of being pulled-in as evidence of our desire to be near someone or something.  This idea is troubling for the OCD sufferer who feels a strong need for certainty about the meaning of attraction, particularly when the false assumption is being made that all attraction is sexual attraction.

I often hear the question, “Am I attracted to this person?” from my clients.  I’m never quite sure how to answer it because it is a loaded question.  The words themselves only ask if the identified object is one they feel compelled to be near.  Furthermore, the reason for the attraction could be any number of things, positive or negative.  But the meaning my clients are hinting at is usually more along the lines of, “Do I desire to have sexual intercourse with this person?” The idea that I personally could even know what another person truly desires indicates an error in information processing.  What is more striking is the fact that their OCD does not allow them to consider the possibility of being attracted to someone, while concurrently not wanting to engage in sexual behavior with that person.

Every person is capable of identifying others as “attractive”.  This means that a person, regardless of gender, meets some set of criteria that is personally and culturally seen as attractive.  For Westerners, this may have something to do with musculature, bone structure, and/or facial symmetry.  But according to researchers, ancient Mayans apparently had a cultural preference for those who were cross-eyed and had flat foreheads.  In other words, “attractive” is not a fixed concept, and has different meaning for different people.

When we look at an attractive landscape in nature, we desire to be near it.  When we see an attractive person, this also compels us to linger.  In some cases it may be envy that draws us in.  Saying, for example, “I wish I had a body like that.”  But in many cases, it’s just giving a thumbs-up to the universe.  “Good one, Universe, you made an attractive person”.  But for the person suffering with Gay OCD, this triggers abject horror.

I often get asked the question, “Do you think I’m gay?”. After the usual therapist-speak of “Does my opinion matter?  Why do you want to know? And what would it mean to you if I thought you were?”, I suggest that my clients study the evidence with me.  The test is not very thorough.  It has one, simple question, with a few optional follow-ups:

“Do you like to have gay sex?”

That’s pretty much all we need to know in order to determine whether or not we should get busy with the work of treating their OCD.

I have seen clients with OCD who also happen to be gay.  They obsess about the same things that other OCD sufferers struggle with, except quite notably that they don’t obsess about their sexual orientation.  The only exceptions to this are gay clients who obsess about the possibility that they might actually be straight.  And I have never had a homosexual client tell me they weren’t sure if they liked homosexual sex.

On the other hand, for straight individuals with Gay OCD, their biggest fear is often that they will seek therapy for unwanted thoughts about their sexual orientation, and that the therapist will tell them that these thoughts indicate that they must actually be gay.  Unfortunately, this often happens when clients end up with ill-informed treatment providers who don’t understand what constitutes Obsessive Compulsive Disorder, and illuminates the importance of finding a therapist who thoroughly understands OCD and its appropriate treatment with Cognitive Behavioral Therapy (CBT).

To put it as simply as possible, gay thoughts are not unwanted by homosexuals.   For homosexuals, gay thoughts are what psychologists call ego-syntonic thoughts.  That’s just a fancy way of saying that their gay thoughts are in keeping with their true values and desires.  Conversely, for heterosexuals, gay thoughts are ego-dystonic, which simply means that the thoughts are in opposition to their true values and beliefs.  Furthermore, gay people like to have gay sex, while straight people with Sexual Orientation OCD are terrified of having gay sex.

Part two of this series provides an in-depth explanation of how we treat Sexual Orientation OCD with Cognitive Behavioral Therapy (CBT), with an emphasis on Mindfulness, Cognitive Restructuring, and Exposure and Response Prevention (ERP). Part two can be found at www.ocdla.com/blog/sexual-orientation-hocd-gay-ocd-treatment-2-1042.

Part three of this series provides an in-depth explanation various sub-types of Sexual Orientation OCD, and variations in their treatment CBT, ERP, and mindfulness. Part three can be found at www.ocdla.com/blog/sexual-orientation-ocd-hocd-sub-types-treatment-1198.

Part four of this series examines common challenges seen in the course of treating Sexual Orientation OCD. Part four can be found at http://www.ocdla.com.

•Jon Hershfield, MA, is a psychotherapist at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions.  Jon can be contacted at jon@ocdla.com.

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“If I knew then what I know now.”

Chances are, if you’re reading this, you’ve found yourself saying the same thing at some point in your adult life.  Nowhere is this more relevant than from the perspective of someone looking back on a childhood with Obsessive Compulsive Disorder (OCD) or an Obsessive Compulsive Spectrum Disorder.  When I meet a new client under 18, there is a powerful sense of traveling through time.  I think, “If only I had someone like me to go back and talk to me when I was someone like this.” How much time might I have saved being able to resist repetitive, unnecessary rituals?  How many more events, relationships, and simple moments of peace might I have been able to enjoy if only I had known what was really happening to me?

When I work with adults, I often find them lamenting the passage of time under the oppressive boot of their condition.  This illuminates the importance of early detection and treatment.  While the onset of OCD and many OC Spectrum Disorders is most likely to hit near adolescence (statistically somewhat earlier for males), it is not uncommon for decades to pass between the initial onset of symptoms and finally finding appropriate, effective treatment.

Diagnosis of OCD and OC Spectrum Disorders

OCD can sometimes be difficult to diagnose in children because ritualized behavior is a healthy part of the learning process.  Diagnosis requires that the treatment provider be able to recognize clinical OCD symptoms, including excessive, repetitive behaviors, extreme perfectionism, expressions of chronic or acute bouts of guilt, and, most importantly, impaired functioning.

OCD and OC Spectrum Disorders share a common dyad of symptoms:  obsessions and compulsions.  This is true whether the diagnosis is OCD, Social Anxiety Disorder (social phobia), Body Dysmorphic Disorder (BDD), Hypochondria (health anxiety), Panic Disorder, Phobias, Trichotillomania (compulsive hair pulling) or Dermatillomania (compulsive skin picking).  Here is a brief breakdown of some of the symptoms parents and educators might observe:

Obsessive Compulsive Disorder (OCD)

• Obsession:  any intrusive thought that represents a threat to identity or health (i.e. contamination, doubt about completing actions, moral perfectionism, “bad” thoughts such as harm coming to parents or pets)
• Compulsion: any ritualized behavior designed to reduce discomfort (i.e. handwashing, reassurance seeking, physically or mentally checking that something has been completed or resolved, thought neutralizing)

Social Anxiety / Social Phobia

• Obsession:  fearful thoughts of being evaluated negatively by others
• Compulsion: repeated school avoidance or skipping classes; avoidance of social situations; chronic negative self-evaluation

Body Dysmorphic Disorder (BDD)

• Obsession: constant distressing thoughts about being ugly
• Compulsion: avoidance of social activities; school avoidance; constant checking of appearance in mirrors; repeated reassurance seeking about appearance

Hypochondria / Health Anxiety

• Obsession: excessive fear of having a serious disease, illness, or medical condition
• Compulsion: repeated checking of body for “symptoms”; repeated asking for reaassurance about health concerns; excessive time spent online researching medical issues

Panic Disorder

• Obsession: intrusive thoughts of having a panic attack; fear of losing control or being overwhelmed and annihilated by anxiety
• Compulsion:  avoidance of situations that the individual fears may trigger a panic attack or situations that in which a quick exit is not easy

Phobias

• Obsession: excessive fear of a specific object, situation, or event
• Compulsion: consistent avoidance of that specific object, situation, or event

Trichotillomania / Dermatillomania

• Obsession: fear that resisting an urge to pull hair or pick skin will result in unmanageable discomfort and/or fears that skin or hair does not look “right”
• Compulsion: giving in to urges to pick or pull, avoiding situations where picking/pulling might be noticed or might be difficult to engage in, camouflaging evidence of pulling/picking behavior

In addition to the primary symptoms of these conditions, children and adolescents with OCD and OC Spectrum Disorders may have great difficulty functioning socially and academically.  If they have OCD, they may spend inordinate amounts of time re-reading or re-writing homework and classroom assignments.  They may also have great difficulty concentrating while being bombarded with unwanted thoughts that cause them to silently suffer.  Likewise, children with Social Anxiety and /or Body Dysmorphic Disorder may have difficulty integrating themselves socially for fear that they will be teased or judged negatively, while kids with Hypochondria may be so consumed with health concerns that they pay little attention to academmic or social activities.  Kids with Panic Disorder may avoid parties because of a fear that they will panic and be humiliated, while those with phobias may avoid field trips or other school activities.  And those with Trichotillomania or Dermatillomania may feel a need to isolate themselves from the observations of others.

Treatment of OCD and Related OC Spectrum Disorders

Numerous research studies have consistently found that Cognitive Behavioral Therapy (CBT) is the most effective treatment for OCD and OC Spectrum Disorders.  The “cognitive” part of CBT helps children and adolescents with OCD and OC Spectrum Disorders develop the ability to acknowledge and modify the distorted thinking that is endemic to these conditions.  This represents a unique challenge for children.  Brain development is literally still in process until around age 24, meaning the raw materials for information processing are still being organized at the age that symptoms of OCD and OC Spectrum Disorders often first appear.  This has implications for treatment, requiring a trained professional to educate clients on the tools of cognitive restructuring in such a way that makes sense to a young sufferer.  Simply put, being able to recognize distortions in the thoughts you have about your thoughts requires a state of awareness that does not come easily for children (or anyone for that matter).  It is a learned technique.

When treating OCD and OC Spectrum Disorders, the “behavioral” component of CBT focuses primarily on a tool called Exposure and Response Prevention (ERP), and in the case of Trichotillomania and Dermatillomania, a technique known as Habit Reversal Training (HRT).  In dealing with any of the conditions noted above, this means learning to accept and tolerate feelings of anxiety, while at the same time resisting a powerful urge to respond.  For children, this is an alien state of being, something that requires mindfulness to accept.  If the compulsion makes them feel better now, it’s a tough sell to voluntarily aim for long-term benefits.  They must believe it will work even while it makes them temporarily feel worse!

Overcoming fear is primarily about returning things to their natural place.  The first day at a new school is terrifying for many kids because the school and the people in it carry a value that is both magical and scary.  But after going to school every day over an extended period of time, while committing to other behaviors like schoolwork and socializing, the “school” eventually returns to its natural place as just a school.  This metaphor applies equally to the unwanted internal experiences seen in OCD and OC Spectrum Disorders, the goal being to return these experiences to their natural state as “just” unwanted thoughts, feelings, sensations, and urges.

In short, we all feel anxiety throughout life, increasing exponentially at the age we start realizing that we must behave a certain way to get the things we want, and that crying doesn’t get us everything anymore.  But the only thing more painful than the relentless unwanted thoughts and needless demoralizing behaviors that come with OCD and OC Spectrum Disorders is the sense of isolation that accompanies them.  In most cases, clinically significant cases require individual treatment with CBT.

Many young people with OCD and related conditions also benefit from structured group therapy as an adjunct to individual treatment.  Tackling an anxiety disorder with a trained treatment provider, while in the company of peers going through the same or similar challenges, often presents the best environment for recovery.  People who have successfully learned to manage OCD and OC Spectrum Disorders often report that discovering they were not alone was one of the strongest catalysts toward change.  So for children, simply being in a room with other young anxiety sufferers can be instrumental in their recovery.  Not only do they get to share their experiences in a non-judgmental format, but they get a unique opportunity to see their internal struggle played out through others.  This is often the first step toward practicing mindfulness, the ability to observe your thoughts and feelings from a more impartial perspective.

Children develop OCD and OC Spectrum Disorders for a combination of reasons.  A history of anxiety disorders in first-degree relatives make a child five times more likely to develop a similar disorder, but genetics are not the only culprit.  The young brain is constantly creating new networks of learned behaviors, so watching how mom and dad cope with stress and fear contributes heavily to the relationship a child has to unwanted thoughts.  Practicing maladaptive coping skills over time can make the ritual the norm and the norm ritualistic.

There is also research indicating a link between negative expressed emotion in a household and early onset of OCD.  If you have a predisposition to developing an anxiety disorder, being raised in an environment that is overly critical or saturated with shame is likely to bring this predisposition to the surface.

This means that treating children necessarily involves educating parents.  Every family session I have begins with parents asking the same question:  “What can I say or do not to make things worse”? Families commonly get trapped accommodating the behaviors associated with their child’s anxiety disorder because denying reassurance or intervening in a ritual can cause their child incredible pain and stress.  However, if children can learn to talk back to their disorder and parents can learn how to partner with them in this challenge, remarkable change can occur.

By and large, many children do not like therapy.  Most of what they know about therapy comes from what they see in movies and television.  They don’t want to be labeled as ill and they don’t want to sit in a room with some old stranger asking about their private thoughts and feelings.  They also don’t like homework!  So treating children using Cognitive Behavioral Therapy requires patience, a sense of humor, and a variety of therapeutic tools aimed at empowering the child to fight back against the disorder and treat themselves.  When treating OCD and OC Spectrum Disorders in children, the right combination of clinical treatment, peer normalization, and family support can create a sturdy platform for healthy adulthood.

Note: the OCD Center of Los Angeles offers a bi-weekly therapy / support group specifically for children and adolescents aged 12-17 suffering with OCD and OC Spectrum Disorders.  For more information contact the center at (310) 335-5443.

•Jon Hershfield, MA, is a psychotherapist at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions.  Jon runs the center’s bi-weekly child / adolescent therapy and support group.  He can be contacted jon@ocdla.com.

I was surprised to discover that Webster’s dictionary defines “hoard” as a kind of temporary fence put up around a structure being built, presumably with the intention of protecting it in a fragile state.  Dictionary.com had a more familiar definition: “to accumulate for preservation, future use, etc., in a hidden or carefully guarded place.”  Both definitions refer to the behavior of creating certainty around an uncertain state.

Squirrels hoard acorns to make sure they don’t starve during the winter.  Armies hoard weapons to ensure they never run out.  And some people with Obsessive Compulsive Disorder (OCD) hoard objects of uncertain value, usually with the belief that the object’s value may be revealed at an important point in the future. A classic example is the OCD sufferer who won’t throw out old newspapers for fear that he may wish to reference an article at a later date.  Some people hoard various items of little or no real value for fear that they may need them some day, or fear that they may not be disposing of these items correctly and could cause unwanted consequences.

Not all people with OCD hoard.  In fact, not all hoarders even have OCD.  However, many people who suffer from OCD appear to engage in a form of mental compulsion I have come to call memory hoarding.

Memory hoarding is a mental compulsion to over-attend to the details of an event, person, or object in an attempt to mentally store it for safekeeping.  This is generally done under the belief that the event, person, or object carries a special significance and will be important to recall exactly as-is at a later date.  The memory serves the same function for the mental hoarder that the old newspaper serves for the physical hoarder.

People with memory hoarding OCD exhibit two major errors in information processing.   The first error is the distorted belief that they will need this memory someday, and that it would be catastrophic if the memory weren’t 100% accurate.  Second, people with memory hoarding also have the distorted belief that memories can be treated the same way as inanimate objects.

The value of a newspaper article can be debated, but the contents of that article will remain constant.  A photograph can capture a certain image, and that image will remain constant as long as the material upon which it’s printed holds up.  But memories do not obey the same properties.

Not only is a memory a complex amalgam of all of your senses (sight, hearing, smell, and so on), but it is also a function of the emotional state and cognitive processes of the person forming the memory, both at the time the memory is being formed, and when it is being recalled.  Therefore the very act of forming or recalling a memory must, by definition, distort it. When you reflect upon an event, you are necessarily filtering the stored data of the initial memory through the present state you are in.  So the belief that a memory can be hoarded makes the memory hoarding compulsion a guaranteed disappointment for the individual with OCD.

In general, the clients we have seen who engage in memory hoarding compulsions are concerned that moments in time will pass without them fully understanding, remembering, and appreciating them.  The uncertainty surrounding whether or not they will be able to adequately reflect upon and evaluate the significance of specific events, people, or objects causes discomfort which they hope to avoid.  Someone without OCD may best understand this concept as akin to that “last look” we all take the moment we leave an apartment from which we just finished moving all the boxes.  You stop, you consider that this is the last time you will be this person in this place, and then you move on to the next chapter in life.

Someone with OCD who is engaging in memory hoarding symptoms is likely to feel trapped in a state of never fully being able to take in the true value of this moment.  The twisted irony of memory hoarding is that the person trying to perfectly remember things frequently misses out on those very things because they are caught up in the mental compulsion trying not to miss anything.  When we don’t allow ourselves to be present in the moment, we are losing a great deal of the value of life in the process.

This irony is consistent throughout the OCD spectrum.  The compulsive hand washer scrubs furiously over and over and yet still spends most of their time feeling dirty, no matter how much they wash.  The washing actually informs the brain that dirt is on the offensive.  The memory hoarder similarly feels a perpetual state of incomplete memory formation, despite all of the time-consuming and emotionally draining work they put into trying to form memories perfectly.

As in other manifestations of OCD, the form may change but the function remains the same.  Here are some forms of memory hoarding we have noticed in our clients:

• Over-attending to, and dwelling on, an event of perceived importance while the event is taking place (i.e. a wedding, a graduation, a birth, etc.)

• Over-attending to the details of a significant moment (an important conversation, a kiss, a bite of food, etc.)

• Over-attending to the details of a location and what it feels like to be in it (a room, the inside of a car, etc.)

• Over-attending to memory triggers of significant life periods (i.e. a movie from your childhood, pictures from an earlier relationship, etc.)

• Trying to perfectly remember the physical details of a lover, friend, or family member.

• Mentally replaying an event multiple times to gain certainty that it was remembered correctly.

Treatment for memory hoarding is obviously not going to look the same as treatment for physical hoarding.  The goal isn’t to remove memories.  Rather, the goal is to be able to accept memories as they are and choose their value willingly, not compulsively.  Thus, the practice of Mindfulness-Based Cognitive Behavioral Therapy should be employed in the order of its name.

• Mindfulness – Fully and willingly accept that you have thoughts which appear on the surface to pose a threat to your ability to fully and perfectly form or recall a memory.  Recognize that these thoughts are not good or bad, but simply exist.  Accept imperfect memories as they are.

• Cognitive (Restructuring) – Identify what distorted ideas you may have about your memories, and what the logical, rational, and evidence-based consequences are of having an imperfect memory of a given event, person, or object.

• Behavioral Therapy (Exposure with Response Prevention) – Intentionally seek out scenarios where you feel the urge to memory hoard, and resist the compulsion by moving through the event without over-attending to any specific detail for a significant amount of time.  Leave an event, person, or object without checking to make sure it has been fully understood, remembered, and appreciated.  Interrupt mental reviewing with more meaningful, attention-demanding activities.

It’s important to understand the meaning of “over-attend” in this context.  One person’s version of savoring the moment in a healthy way could mean getting trapped in an obsessive-compulsive cycle for someone with OCD.  The trick is to draw a distinction between enjoying a moment, and mentally seeking reassurance by asking yourself if you are completely enjoying and remembering a moment for sure.

Part of this phenomenon may have to do with an OCD sufferer’s difficulty accepting the permanence of the passing of time.  Or perhaps memory hoarding is just another form of trying to do the right thing in the right way 100%.  In any case, if the ultimate objective is to value and enjoy experiences in your life, then your best bet is to let those experiences happen without OCD telling you how to enjoy and remember them.

•Jon Hershfield, MA, is a psychotherapist at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions.  He can be contacted jon@ocdla.com.

Our two most recent entries discussed a Scottish case and an American case in which criminal defendants claimed that the crimes for which they were being prosecuted were a function of their having Obsessive Compulsive Disorder (OCD). This week, we examine a case of an Australian professional boxer who claims his assault on 70-year-old man came about as a result of his having OCD.  Part three of a three part series examining OCD and the law.

On November 16, 2009, John Edward Lane, a 70-year-old retired Australian television executive boarded a ferry boat in Sydney harbor.  Also on board was Grant Brown, a 31-year-old Tasmanian boxer who had previously held the Australian lightweight title for three years, as well as six Tasmanian boxing titles and four Golden Gloves titles.

According to witnesses, Brown had a contentious argument with his girlfriend on his cell phone during the ferry ride. After the call ended, Brown was reported to be upset and aggressive, angrily kicking the walls of the boat.  At some point, an associate of Mr. Lane asked Brown to settle down, to which Brown responded that he was going to “bash your head in”.  When the 70-year-old Mr. Lane then asked Brown to relax, Brown replied “Step away, I swear I’m going to punch your f ***ing head in”, and then punched Mr. Lane once in the face.  Lane fell to the ground, bleeding profusely, and suffered a fractured skull, spine and eye socket.

Brown was arrested for the assault, and when originally presented to the local court, his attorney claimed Brown was suffering from depression and relationship problems that had factored into his assault on Lane.  He further requested that his client be released without bail because of his “good character” and lack of a prior criminal record, as well as his having shown remorse for the assault on Lane.  The court magistrate wisely refused bail on the grounds that Brown had perpetrated “unprovoked violence for no apparent reason”, and was a danger to the community.

When Brown’s case was later brought before the court on April 9, 2010, his defense attorney claimed that his client had depression and Obsessive Compulsive Disorder (OCD), and that his assault on Lane was a result of his mental illnesses and his having run out of his medication at the time of the crime.

But the magistrate in the case, Judith Fleming, rejected Brown’s request that the case be thrown out of court.  According to The Herald-Sun, Ms. Fleming noted that “distressing phone calls and feeling annoyed with other passengers on public transport were common occurrences that shouldn’t end in violence”.  The paper further reported that the the magistrate found “no indication in the psychological reports submitted to her that Brown’s illnesses caused aggression” and that “if anything, the reports talk about withdrawal” from his medication, rather than the illnesses themselves,   as a possible factor contributing to Brown’s behavior.

Brown ultimately pled guilty, and on June 10 2010, was sentenced to two years in prison, with no possibility of parole for a minimum of 18 months.  In sentencing Brown, the magistrate described the the former boxer’s actions as  “a cowardly and vicious attack on an elderly gentleman on public transport where the victim was utterly blameless”.  Brown is currently out on bail pending appeal.

This is just another in a recent spate of cases in which defendants and their attorneys have attempted to excuse criminal behavior on the grounds of having Obsessive Compulsive Disorder (OCD).  In this case, as in the others presented in earlier entries here, the court was able to clearly see through the rhetoric being presented by defense attorneys.  The magistrate recognized that the defense presented no evidence of a link between aggressive behavior and OCD – because there is no evidence of such a link.  She also noted that being upset after a difficult phone call with a lover is a fairly normative experience that doesn’t excuse subsequent criminality.

Let’s hope that the disposition of the cases presented in our three-part series on “OCD and the Law” is a harbinger of a broad rejection of efforts by defendants and their attorneys to mislead judges and juries with specious arguments about criminal activity being caused by OCD and other mental illnesses.

•Tom Corboy, MFT, is the director of the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions. He can be contacted director@ocdla.com.