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.

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.

In March of 2010, the lawyer for Jerry Seidl of suburban Louisville, Kentucky claimed that his 68 year-old client murdered his wife of 47 years as a result of Obsessive Compulsive Disorder (OCD).  The couple had separated in 2008, and his wife Dorene had moved out of the family home.  On August 7th of that year, after filing for divorce, Dorene sought a protective order on the grounds of domestic violence.  In the petition, Dorene claimed that her husband had previously put a gun to her head, and on a separate occasion had told her “I’m just going to kill myself and get it over with. Do you want to go with me”.  Despite this, the request for a protective order against her husband was rejected by a local judge on August 20th.

Less than a week later, on August 25^th, Dorene returned to the family home to collect personal effects and to present her estranged husband with a note explaining what she felt she was due financially.  It was at that time that the defendant drew a gun and shot his wife in the head five times, wounding her fatally.  He then barricaded himself in the home for four hours until peacefully surrendering to the local SWAT team.

In presenting his final argument to the jury, Seidl’s defense attorney Bart Adams claimed:

“Our defense in this case is he had obsessive compulsive personality disorder,” said defense attorney Bart Adams. “People with obsessive compulsive disorder are driven by an unwarranted but unrelenting pressure to control all persons and objects around them. He lost control, there’s no doubt about that. He’s got to pay for what he did. He knows that I know it, everyone in this courtroom knows, but we’re going to prove to you that it was murder under extreme emotional disturbance.”

The primary flaw with the argument presented by Seidl’s lawyer is quite simple – he first claims that Seidl has Obsessive Compulsive Personality Disorder (OCPD) and then, in the very next sentence, says that his client has Obsessive Compulsive Disorder (OCD).  But Obsessive Compulsive Disorder (OCD) is not the same as Obsessive Compulsive Personality Disorder (OCPD).  In fact, despite the similarity of the two terms, the two conditions are actually quite different.  They are essentially the opposite of each other.

An individual with OCD has very specific thoughts which are experienced as unwanted, intrusive, and anxiety provoking.  The clinical term for these types of thoughts is that they are ego-dystonic, which simply means that the thoughts are inconsistent with the individual’s values, beliefs and character.  For example, some individuals with OCD might have unwanted thoughts about homicide, pedophilia, or sexual orientation.  The individual with OCD experiences these thoughts as completely unwanted, highly disturbing, and incredibly disgusting.  They feel horrible that that they are experiencing these unwanted thoughts, and go to great lengths in an effort to get these thoughts out of their mind.  They never act on these thoughts.

Conversely, an individual with OCPD has thoughts which they experience as wanted, normal, and not at all anxiety provoking.  The clinical term for these thoughts is ego-syntonic, which simply means that the thoughts in OCPD are consistent with the individual’s values, beliefs and character.  For example, some individuals with OCPD might have the thought that their clothes should be folded a very specific way or that their yard should always be 100% free of leaves.  The individual with OCPD experiences these thoughts as completely normal and reasonable, and expects others to comply with their desire that certain behaviors be done in a very precise and specific manner.  They do not feel bad about these thoughts, and make no effort to get these thoughts out of their mind.

In presenting his case to the court, Seidl’s attorney called upon a local psychiatrist, Dr. Douglas Ruth, who testified that Seidl suffered from OCD, which Ruth claimed caused Seidl to be “controlling” and to “snap” when his wife asked for a divorce.  Perhaps Dr. Ruth should return to school to get a better understanding of the difference between OCD and OCPD.  There is nothing in reports of the Seidl case to indicate that the defendant had OCD.  And as prosecutor Christie Foster noted, Seidl had never previously been diagnosed with OCD.  In fact, Seidl’s lawyer describes his behavior as being “driven by an unwarranted but unrelenting pressure to control all persons and objects”, which is actually a pretty good description Obsessive Compulsive Personality Disorder.

Of course, this raises the question of whether or not OCPD should be an acceptable defense for murder.  Seidl’s attorney indicated in court that his client deserved some sort of special consideration because he murdered his wife “under extreme emotional disturbance”.  But aren’t all (or at least most) acts of murder committed under extreme emotional disturbance?  Is being in a bad emotional state now an excuse for murder?

Apparently the jury in the Seidl case didn’t think so – after only four hours of deliberation, they returned a guilty verdict, and recommended a 35 year prison term.

Next week – Professional boxer Grant Brown assaulted a 70-year-old retiree, resulting in a fractured skull and permanent brain damage…and then claimed his OCD made him do it.

•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.

In March 2009, the Edinburgh Evening News of Scotland reported the case of Iain McKinlay, a father of three who claimed that the huge amount of child pornography that he had amassed on his computers was a result of his suffering from Obsessive Compulsive Disorder (OCD).  McKinlay was caught after he used his personal credit card to access child pornography web sites.  When the local police raided his home in April 2008, they found 3,557 illegal pictures on two separate computers.

McKinlay’s initial explanation for his collection was somewhat reminiscent of the pedophiles seen on NBC’s “To Catch A Predator”, in which nearly all of those caught on camera claim that they were under the impression that the young child they ostensibly came to meet was actually much older (this despite the video and audiotapes proving that they were explicitly looking for young children).  In McKinlay’s case, he claimed that he was conducting internet searches specifically for young women aged 18-21, and that the search engines somehow mistakenly presented him with the illicit photographs of minors.

McKinlay’s lawyer took a different approach, claiming that his client’s child pornography collection was evidence of Obsessive Compulsive Disorder (OCD), and that his collecting and viewing the pictures “helped him escape from the pressures of reality”.  McKinlay’s lawyer went on to claim that his client should not receive jail time because he was not likely to return to viewing and collecting child pornography, despite the fact that he had been previously convicted of other sex crimes.

Unfortunately, many people, including judges and juries, could potentially be swayed by the argument made by McKinlay’s lawyer that this was a case of OCD.  After all, McKinlay’s behavior (collecting and viewing child pornography) seems “obsessive” and “compulsive“.  But in assessing the merits of the defense attorney’s argument, it is important to note three salient issues.

First – there is absolutely no connection between compulsive pornography viewing and OCD.  There are many problematic behaviors that have obsessive and compulsive components, yet are not the same as OCD, including anorexia, bulimia, compulsive overeating, compulsive gambling, compulsive shopping, compulsive shoplifting, drug addiction, alcoholism, sex addiction…and pedophilia.  It is clear from news reports about this case that McKinlay enjoyed looking at pictures of naked children.  After all, he had collected over 3,500 pornographic pictures of children at the time of his arrest.  This suggests pedophilia…not OCD.

Second, people with OCD do not act compulsively in an effort to “escape from the pressures of reality”, as McKinlay’s lawyer claimed in this case.  Those who suffer from OCD act compulsively with the sole intent of reducing or eliminating the overwhelming anxiety that they experience related to very specific unwanted thoughts.  In other words, they perform compulsive behaviors to counteract unwanted thoughts that they find extremely distressing.  I fail to see how McKinlay’s collecting and viewing of child pornography was driven by an effort to reduce or eliminate any specific unwanted thoughts.  On the contrary, his habit quite clearly seems motivated by a desire to satisfy his sexual urges.

Third, it is worth noting that there is a sub-type of OCD in which people have unwanted sexual thoughts, including thoughts about children.  But in cases where individuals with OCD have obsessions about children, they are uniformly disgusted by those thoughts.  In 15 years of treating people with OCD, I have never once seen a client with obsessions about children act on these thoughts.   In fact, those with obsessions about children often go to the opposite extreme, avoiding all contact with children (even their own) because they are so horrified by these unwanted thoughts.  They never seek out pornographic pictures of children.  Never.

Fortunately, the judge in the case was not fooled by the lawyer’s specious argument.  He sentenced McKinlay to nine months in jail, and placed him on the local sex offenders registry for the following ten years.

Next week – Jerry Seidl shot his estranged wife in the head five times…then claimed his OCD made him do it.

•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.

“If I hate OCD so much, why do I fight so hard to keep it around? Maybe my OCD is a good thing. Maybe I need my OCD. After all, If I am not my OCD, then who am I?”

This scenario typically (although not always) presents itself several months into therapy, long after the client has gained some autonomy from their OCD through the use of Cognitive Behavioral Therapy.

Cognitive Behavioral Therapy and the OCD Stockholm Syndrome

Effective treatment for OCD focuses primarily on two Cognitive Behavioral Therapy techniques. The primary cognitive technique used in treating OCD is Cognitive Restructuring.  This technique works by teaching you how to recognize the distorted thinking that builds layers of obsessive fear around you.  The primary behavioral technique used in treating OCD is Exposure and Response Prevention (ERP).  This technique works by peeling off the layers of fear and exposing your mind to freedom from compulsions.  Combined, these CBT techniques are the gold standard for the treatment of OCD and related anxiety disorders.

“But what if the layers of fear are peeled off only to reveal nothing inside?  What if I’m an empty shell?”

Ironically, the appearance of this new fear is often actually a sign that CBT is working.  Since the first time you touched that doorknob and resisted washing or sat alone with a defenseless child while imagining the unimaginable, you’ve had your OCD on the run.  Always looking for its next in, the OCD starts grasping at straws.  The final straw, it claims, is that you need your OCD to be who you are.  This is certainly among OCD’s more cynical traps.

While virtually all clients recognize that life without countless, misery-inducing rituals is better, some people with OCD actually start to advocate for keeping some of their compulsions.  The thinking appears to be that some compulsions are worth hanging on to, and it becomes important for the sufferer to defend them.  The therapist becomes the bull in the brain’s delicate china shop, destroying a carefully constructed self-preservation system.  This opens the door for OCD to attack the one weapon essential for successful treatment: a client’s motivation.

One client often struggles with capturing the motivation to do his ERP homework assignments.  Sometimes the ERP assignments are not as terrifying as he had anticipated they would be and this causes a new problem.  Here is what his OCD exclaims:

“See…this is too easy!  You can do it and your so called OCD will be gone before you know it.  Your therapist will send you off as soon as he figures out your OCD is really not that bad, and before you feel ready.  He has lots of other clients who are probably way worse than you and you would be selfish to ask for any more of his time.  And when he kicks you out, you’ll be lost and confused and wonder whether it was all a lie, and you’ll feel terrible for ever having presumed that your problems were any different than anyone else’s problems or that your problems were bad enough for you to seek special treatment when there are so many out there who have it way worse than you.”

The reason we so often lose at playing the OCD game is that it cheats.  We play fair.  We use logic.  But OCD comes to the knife fight with automatic weapons.  It is willing to go so far as to deny its own existence in order to preserve that same existence.

Well, I have good news and bad news.  The bad news is you will have unwanted intrusive thoughts (everybody does), and somewhat unusual strategies for coping with them, for the rest of your life.  The good news is that, if you accept those thoughts, they need not be so problematic.  Unwanted thoughts happen.  What they mean about you is just an ongoing debate between you and your OCD.  But the effect they have on your functioning is the difference between having a disorder and just being you.

Mastering The OCD Stockholm Syndrome

As with any OCD fear, the way to master the OCD Stockholm Syndrome is to habituate to it through ERP.  For some this may mean being vigilantly compliant with therapy and risking suddenly finding yourself without OCD.  It may mean tolerating uncertain thoughts of being a fraud, a fake, or a deceiver of the mental health world.  It may mean feeling like you don’t deserve quality treatment because you don’t really suffer as much as you think one should.

On a cognitive level, mastering the OCD Stockholm Syndrome means engaging in your ERP homework without first capturing that “feeling” which makes you believe you are motivated to do the work.  In other words, change the behavior first, and then wait patiently for your thoughts and feelings to catch up.

The processing error that allows OCD Stockholm Syndrome to take shape involves a distorted belief that, in the future, you will be the same person, but without all the time consuming rituals to rely on.  However, this ignores the fact that without the rituals, you can actually evolve.  The person you become – the person who lives without the constant terror of OCD – relates to that fear differently than the person who suffers under its reign today.

The light at the end of the tunnel remains as long as you stop checking to make sure it is there.  Stay in the present, but always move forward.

•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.

Traditional Treatment Strategies for OCD and Anxiety

Before the development of psychological treatments, disorders such as OCD and other anxiety conditions were often considered spiritual problems.  The sanctioned response was to do your compulsions harder and more frequently.  And for those who drew too much attention, a not uncommon result was persecution, imprisonment, or being subjected to brutal, misguided experiments.

When psychoanalysis became the new fad, the approach was to talk about your obsessions and compulsions while intentionally attributing meaning to the content of your thoughts.  With the help of their analyst, people with OCD and anxiety sought to find the secret, deep-seated meaning behind their obsessive thoughts.  This was worse than pointless – it was a disaster.  Today, the very idea that obsessions have some subconscious meaning is rejected by all OCD experts.  Unfortunately, earlier generations of those with OCD and related anxiety conditions spent years in psychoanalytic therapy trying to find meaning in thoughts that are essentially meaningless.

Behavioral and Cognitive Strategies for OCD and Anxiety

The next chapter to unfold was behavioral therapy, in which the primary focus was not on what we think or feel, but on what we do.  By sometimes literally forcing people to expose themselves to what scares them, people with OCD and other anxiety disorders would stop reinforcing distorted thoughts and maladaptive behaviors.  But the results were mixed.  Resisting the urge to do compulsions or avoidant behaviors provides relief, but doesn’t leave the sufferer with much of a strategy for their obsessive thinking.  Like crash diets, results come quickly, but often return – sort of like when contestants on The Biggest Loser go back to their old eating habits and re-gain most of the 150 pounds they lost.  With strict behavioral therapy, the individual often sees a quick reduction in OCD symptoms, but they don’t learn a different way of thinking about their anxiety.  When the anxiety returns, often the OCD returns with it.

Then came cognitive therapy, which recognized that the anxiety-provoking thoughts were often just plain wrong.  From a cognitive therapy perspective, OCD and other anxiety disorders develop because our thoughts are distorted, and we craft poor cognitive strategies for addressing them.  Unfortunately, while this perspective provides some relief, it doesn’t always result in less time at the bathroom sink.

Combining the two theories into Cognitive Behavioral Therapy (CBT) was the real breakthrough in treatment for Obsessive Compulsive Disorder and related anxiety conditions.  With CBT, the client challenges his/her distorted thinking with rational alternatives, and concurrently changes his/her  maladaptive compulsive and avoidant behaviors.  Over a comparatively short period of time, the client learns that the obsessions are not important, and experiences a reduction in the intensity and intrusiveness of the unwanted thoughts.  Empirically speaking, Cognitive Behavioral Therapy  (specifically, Cognitive Restructuring and exposure-based therapies such as Exposure with Response Prevention) has repeatedly been found by numerous controlled research studies to be the most effective treatment for OCD and most other anxiety disorders.

Mindfulness-Based Therapies for OCD and Anxiety

However, something was still missing.  It turns out that people with OCD and other anxiety disorders have the same kinds of thoughts as people without these conditions – both wanted and unwanted.  The primary difference between people with OCD / anxiety and those without an anxiety disorder is not the content of the thoughts, but their perspective on their thoughts.  If one’s perspective is that a particular thought is “bad”, then that thought may become problematic.  In short, the thought is not the problem – the valuing of that thought as a “bad” thought is the problem.  This is where Mindfulness-Based Cognitive-Behavioral Therapy (MBCBT) comes in to play.

If you can imagine your thoughts as a line of train cars, people with OCD and other anxiety disorders tend to keep stopping the train to make sure everyone has a ticket.  What MBCBT asks is that you simply observe the train passing.  This means acknowledging that unwanted thoughts are occurring, but not evaluating these thoughts as being particularly meaningful.  Instead of changing the content of what the thought itself means, you are changing your perspective towards the thought and how you process the fact that the thought is occurring.  It is not happening to you.  It is simply happening.

MBCBT is, quite simply, the latest fine-tuning of CBT, which is the most effective treatment for OCD and related disorders.  With MBCBT, we don’t try to control what thoughts happen – we choose how we think about our thoughts and how we interact with them.  MBCBT combines the three modalities that research has shown bring about positive change for OCD and anxiety sufferers:  Mindful Acceptance (a non-judgemental relationship to our thinking), Cognitive Restructuring (challenging distorted thoughts with more rational alternatives), and Behavioral Modification (changing what we do in response to our unwanted thoughts).

Ultimately, freedom from OCD and anxiety is not the eradication of unwanted thoughts and feelings.  After all, everybody has unwanted thoughts and feelings.  Freedom from OCD and anxiety is the ability to have and accept whatever thoughts and feelings you are experiencing, and to be able to choose which of those thoughts and feelings merit your attention.

•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.

In part 1 of this series, we discussed the growing interest in sex addiction in the wake of recent revelations that Tiger Woods has had a wealth of mistresses.  We also discussed how many people, including professional psychotherapists, inappropriately conceive of sex addiction as a form of Obsessive Compulsive Disorder (OCD).  Finally, we reviewed the inherent experiential differences between these two conditions, as well as the innate problem of trying to treat sex addiction using therapeutic techniques known to be effective for the treatment of OCD.

In light of the significant differences between these two conditions, it seems clear that sex addiction is not OCD.  So what is it?

Sex Addiction as a Diagnosis

The Diagnostic and Statistical Manual – 4^th Edition, (DSM-IV), which is published by the American Psychiatric Association (APA), currently has no specific diagnosis for sex addiction.  However, in its recent proposal for revisions planned for the upcoming DSM-5, the APA has suggested that  “Hypersexual Disorder” be included in the category of Sexual and Gender Identity Disorders.  This would put it on par with other sexual disorders currently listed in the DSM-IV, including Erectile Dysfunction, Premature Ejaculation, Hypoactive Sexual Disorder, Dyspareunia, and Vaginismus, all of which are disorders of functioning.  In other words, these conditions tend to be descriptive of specific ways in which sexual organs or processes are not functioning properly, resulting in limited, difficult, or even impossible sexual activity.  In fact, most (not all) of the sexual disorders listed in the DSM-IV are disorders of functioning.  Taking that into consideration, Hypersexual Disorder may not really fit here.

So if sex addiction is not a sexual disorder, is it an addiction?  The APA has suggested renaming the category of what are currently called Substance-Related Disorders as Addiction and Related Disorders, specifically to allow for the inclusion of “behavioral addictions” such as Pathological Gambling.  A reasonable argument could be made that sex addiction is more of a behavioral addiction than a disorder of sexual functioning, and as such, belongs in this category.

In fact, the very concept of a behavioral addiction seems predicated on the idea that normal, pleasurable activity can become problematic.  For example, one could argue that compulsive overeating is essentially a behavioral addiction, rather than an eating disorder.  (For more on that issue, see our November 2009 article on Compulsive Overeating.)

At the same time, one could also argue that there are significant differences between addictions to mind-altering substances (i.e., alcohol, drugs) and addictions to behaviors (i.e., gambling, sex, eating), most notably the fact that substances can and often do lead to physical dependence, and that those addicted to substances can and often do experience physical withdrawal symptoms.  Can the same be said for behavioral addictions?

An argument could also be made that sex addiction would perhaps be more appropriately classified as an impulse control disorder.  This is an existing diagnostic category that currently covers wildly varying conditions, including Trichotillomania, Pathological Gambling, Pyromania, and Intermittent Explosive Disorder.  There seems little dispute that sex is an impulse, and that in those with sexual addiction, the impulse is not well controlled.

Does Excessive Sexual Activity Warrant a Diagnosis?

And then there is the simple question of whether or not sex addiction is a legitimate disorder at all.  Many contend that sex addiction is really just another example of the APA stretching the bounds of mental illness to include normal variations of human experience.  Others see the very idea of sex addiction as little more than a convenient excuse for bad behavior.  Along these lines, one recent article on LinkedIn was posted under the rather pithy title of Tiger Woods: Sex Addict or Scumbag.

And then there are those who say compulsive sexuality is not even bad behavior, but rather people (usually men) doing what they like to do for the very simple reason that they can.  Some might even argue that one of the primary reasons men like Tiger Woods seek fame and fortune is for the unfettered access to multiple sex partners that comes with success and power.  Many men in the public eye have been described as sex addicts, including professional athletes (Tiger Woods, Wilt Chamberlain), movie stars (Warren Beatty, Michael Douglas), and politicians (Bill Clinton, Eliot Spitzer).  Are they and others like them sex addicts, or merely men fully enjoying the fruits of their labors?

So, the question remains: is sex addiction a sexual disorder, an addiction disorder, an impulse control disorder,  bad behavior, or just people enjoying the benefits of their stature?  There may be no easy answer for how, if at all, to diagnose and classify sex addiction.  Simply put, the human psyche isn’t so easily divided into discrete categories, and our attempts to create an ever-expanding taxonomy sometimes seem more a function of a human need for order rather than any legitimate neuropsychiatric distinctions.  The only thing that is certain in this discussion is that sexual addiction is not OCD.

•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.

Lately, sex addiction has become a hot topic in the news.  Certainly, the biggest factor in this explosion of interest has been the revelation that Tiger Woods has had a seemingly infinite number of extra-marital affairs, and subsequent reports that he is undergoing treatment for sex addiction.

Is Sex Addiction OCD?

Every so often, the OCD Center of Los Angeles receives a call from a prospective client looking for treatment for sex addiction.  These individuals (or their spouses) call us because they believe, or more frequently, have been told by previous therapists, that their sexual behavior is evidence of Obsessive-Compulsive Disorder (OCD).  And invariably, they are surprised and confused when I inform them that sex addiction has absolutely nothing whatsoever to do with OCD.

In fact, the two conditions are radically different.  Yes, both conditions include obsessional thoughts and compulsive behaviors.  But people exhibit obsessive thoughts and compulsive behaviors in a whole host of conditions that are not OCD, including Anorexia Nervosa, Bulimia, Alcoholism, Drug Addiction, Pathological Gambling, Compulsive Shoplifting, Trichotillomania, and Body Dysmorphic Disorder.

So the question arises: what distinguishes sex addiction from OCD?  In a word…pleasure.

Very simply put, individuals who are addicted to sex get pleasure from their behavior.  Conversely, those with OCD get not a scintilla of pleasure from doing their compulsions.  In fact, in fifteen years of treating clients with OCD, I have never once had a client report getting anything resembling pleasure in the course of doing a compulsion.

To better understand how OCD operates, it is helpful to understand the concept of the Obsessive-Compulsive Cycle.  For the person with OCD, obsessions are specific, repetitive thoughts that are experienced as unwanted and extremely anxiety-provoking.  And like all humans, people with OCD don’t like the feeling of anxiety.  As such, those with OCD develop strategies do eliminate or reduce that anxiety.  The compulsive and avoidant behaviors seen in OCD are done with the sole purpose of reducing or eliminating the immediate anxiety caused by these very specific thoughts.  And the compulsions are often done repeatedly and in a ritualized fashion, sometimes for hours, until the individual feels some relief from the anxiety caused by these specific thoughts.  This Obsessive-Compulsive Cycle is consistent and stable in all cases of OCD that I have ever seen.

Now let’s compare that to sex addiction.  Are the obsessive sexual thoughts experienced by a sex addict prior to sexual activity unwanted and anxiety-provoking?  I would argue just the opposite.  It seems to me that the thoughts experienced by sex addicts are arousing and pleasurable.  Some might argue that sex addicts experience various conflicting emotions prior to acting compulsively, including anxiety.  But it seems self-evident that the primary feeling is one of sexual arousal.  The thoughts the sex addict experiences after the fact may be distressing, but prior to that sexual activity, the thought of having sex is primarily experienced as pleasurable and desirable.

Conversely, those with OCD never feel any pleasure related to an obsession.  Not for one second.  Their obsessions are experienced as the worst kind of mental torture.  In fact, on more than one occasion, I have had clients with OCD tell me that would gladly give up a limb if doing so would allow them to be free of their obsessions.

Likewise, the compulsive behavior done by a sex addict, whether it is sex with another person or masturbation, undeniably provides the individual with pleasure.  The individual with OCD gets no pleasure whatsoever from doing compulsions.  The person with OCD gets only a temporary reduction in anxiety related to the very specific fear about which they were obsessing.

Treatment for OCD vs. Treatment for Sex Addiction

Finally, it is also worth noting that if sex addiction is OCD, then by extension, it should respond to the same treatment as OCD.  Multiple controlled research studies have consistently found that the most effective treatment for OCD is a very specific type of Cognitive Behavioral Therapy (CBT) called Exposure and Response Prevention (ERP).  This therapy requires that the client purposely expose themselves to the very object or situation that generates their anxiety.  For example, if one obsesses about contamination, this might mean purposely having repeated contact with specific items that one perceives as “contaminated”.

Applying this principle to sex addiction would suggest that the best treatment would be for the sex addict to purposely and repeatedly watch porn, spend private, non-sexual time with prostitutes, etc.  This is not just unlikely to be a successful intervention – it is very likely to have the exact opposite of the intended effect.  Simply put, asking a sex addict to purposely be around sexual triggers is like asking a heroin addict to purposely be around heroin.

So, if sex addiction is experientially different than all other types of OCD, and it doesn’t respond to the same treatment that is known to consistently be the most effective treatment for OCD, it stands to reason that it isn’t OCD.

Next week, we will continue our discussion by answering the question: “If sex addiction isn’t OCD, then what is it.”

•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.

After ten years of ongoing debate, the numerous APA work groups investigating potential revisions to various diagnoses and categories to be included in a planned fifth edition have presented their suggestions to the APA.  Some of these changes are likely to be as controversial as current classifications in the DSM-IV, while others will pass barely noticed into the new DSM-5 (for example, the switch away from Roman numerals in the title).  A number of these proposed changes directly impact conditions treated here at the OCD Center of Los Angeles.  To wit:

OCD and Anxiety Disorders

The APA is considering changing the name of this category to Anxiety and Obsessive-Compulsive Spectrum Disorders.  This seems completely unnecessary, but harmless.  For years there have been reports that Obsessive-Compulsive Disorder was going to be removed from the Anxiety Disorders category, and reclassified in its own category.  The rationale for this idea was that OCD had been found to have a neurological basis.  That would have been spectacularly ridiculous.  It seems likely that, in time, researchers will discover that many, if not virtually all of the conditions in the DSM have some neurological basis.  The DSM-IV made quite clear that its focus was not on the cause of the disorders it classified, nor on the treatment of those conditions, but rather on the presenting symptoms that define the conditions.  Certainly, one of the primary defining characteristics of OCD is anxiety.  We have treated hundreds of individuals with OCD over the years, and I can comfortably say that the one thing that absolutely unites every single one of them is this – they are highly anxious about their obsessive and compulsive symptoms.

Panic Disorder

Currently, the DSM-IV lists two options for those with Panic Disorder

• Panic Disorder with Agoraphobia
• Panic Disorder without Agoraphobia

The DSM-IV also lists Agoraphobia Without History of Panic Disorder as a separate condition.  The APA is wisely considering condensing the two separate diagnoses of Panic Disorder into one, classified simply as Panic Disorder.  However, they are also planning to maintain Agoraphobia as a separate condition, but minus the “…Without  History of Panic Disorder” appendage.  This is utter nonsense.  In years of treating people with anxiety, I have never once seen a client who experienced Agoraphobia without having panic attacks.  While the theoretical possibility exists of someone having Agoraphobia without having panic attacks, the role of Agoraphobia in that person’s life would be to avoid experiencing a panic attacks.  Even in their new description of Agoraphobia, the APA refers to the fear of “panic-like symptoms” and “anxiety about having a panic attack, panic-like or other symptoms”.  The continuing inclusion of Agoraphobia as a separate condition is pointless and will unnecessarily complicate the diagnostic process.

Body Dysmorphic Disorder (BDD)

Body Dysmorphic Disorder is currently classified as a Somatoform Disorder, along with Hypochondriasis, Somatization Disorder, Undifferentiated Somatoform Disorder, Pain Disorder, and Conversion Disorder.  The APA is recommending two noteworthy changes for the classification of BDD.  First, it is suggesting that BDD be moved from its current category of Somatoform Disorders into the new category of Anxiety and Obsessive-Compulsive Spectrum Disorders.  I couldn’t agree more.  BDD has much in common with OCD and, very little in common with most Somatoform Disorders.

The second proposed change is to add a specifier for Muscle Dysmorphia, in which an individual’s obsession is that his or her body is too small or is insufficiently muscular.  The rationale provided by the APA is that Muscle Dysmorphia has differences from other forms of BDD, specifically higher rates of suicidality and substance abuse, and that the specifier will thus have clinical utility.

Hypochondriasis

The new DSM-5 is proposing to dramatically alter its conception of Hypochondriasis, which, as noted above, is currently classified as a Somatoform Disorder.  The plan is to combine four of the Somatoform Disorders – Hypochondriasis, Somatization Disorder, Undifferentiated Somatoform Disorder, and Pain Disorder –into a new condition called Complex Somatic Symptom Disorder (CSSD).  Conversion Disorder would remain a separate Somatoform Disorder, and BDD, as noted above, would be moved to the new Anxiety and Obsessive-Compulsive Spectrum Disorders category.

I would argue that Hypochondriasis is phenomenologically distinct from Somatization Disorder, Undifferentiated Somatoform Disorder, and Pain Disorder, and that combining it with these conditions ignores that reality.  Simply put, Hypochondriasis is not about the vague physical complaints, pain, or pseudoneurological symptoms seen in these other conditions.  Hypochondriasis is about the abject terror that one has a disease, illness or medical condition that will either result in death, or at the very least a miserable, pain-filled life.  In other words…Hypochondriasis is an anxiety disorder. In fact, the APA is suggests in this revision of the DSM that the fears experienced by those with what has heretofore been called Hypochondriasis now be called “health anxiety”.  As such, it would more appropriately be classified in the new Anxiety and Obsessive-Compulsive Spectrum Disorders category.

Apparently, the framers of the new DSM-5 agree that this is at least a possibility, as they note in their description of CSSD that “if patients present solely with health-related anxiety in the absence of somatic symptoms, they may be more appropriately diagnosed as having an anxiety disorder”.  Agreed.

Trichotillomania

The APA is considering two changes for Trichotillomania.  First, renaming the condition simply as Hair Pulling Disorder.  The Trichotillomania Learning Center (TLC), the largest advocacy and education organization in the world for this condition, has long proposed a name change along these lines.  The primary goals of the name change would be two-fold.  First to reduce confusion about the nature of the condition – let’s face it, as a name, Hair Pulling Disorder is a lot more to the point.  And second, to remove the stigma associated with the condition by virtue of the “-mania” part of its current name.  Hair pulling has nothing to due with “mania” or Bipolar Disorder, so this name change intuitively seems like a good idea.

The other change that the APA is recommending for Trichotillomania is to reclassify the condition in its planned new category of Anxiety and Obsessive-Compulsive Spectrum Disorders.  If this new category indeed gets formed, then this would be a far more appropriate place for Trichotillomania than its current home in Impulse Control Disorders, where it resides with Pathological Gambling, Pyromania, and Intermittent Explosive Disorder, none of which have any relationship whatsoever to Trichotillomania.

Skin Picking Disorder

Finally, the APA is beginning to pay attention to this condition, which the proposed DSM-5 succinctly (if incompletely) describes as “recurrent skin picking resulting in skin lesions”.  Currently, there is absolutely no mention of skin picking as a condition in the DSM-IV. It is as if it doesn’t exist, which would be news to the hundreds of people who have sought treatment at our center for this condition.  Many people believe their skin picking is a symptom of Obsessive-Compulsive Disorder (OCD), primarily because that is what they have previously been told by well-meaning, but misinformed therapists.  While skin picking has certain obsessive and compulsive features, and qualifies as an Obsessive Compulsive Spectrum Disorder,  it is quite different from OCD.  In fact, the condition with which Skin Picking Disorder has the most in common is Trichotillomania.

As a result of its non-existence in the DSM-IV, treatment centers that specialize in treating this heretofore unnamed, but fairly common condition, utilize various different names for it, including:

• Compulsive Skin Picking
• Chronic Skin Picking
• Neurotic Excoriation
• Dermatillomania
  
• Pathogenic Excoriation

Psychologist James Claiborn wrote a great article about this condition a few years back aptly titled Skin Picking: A Disorder in Search of a Name.  Hopefully, the APA will soon rectify this problem.  My only complaint is that rather than classifying Skin Picking Disorder in the DSM-5 as a codable disorder (and thus covered by insurance), the current proposal is to list it in the Appendix for Further Research.   While this condition certainly merits further research, it is hardly an unknown entity.  If the APA, as planned, creates a new category called Anxiety and Obsessive-Compulsive Spectrum Disorders, then this is where it belongs, right along side Trichotillomania.

Olfactory Reference Syndrome (ORS)

Like Skin Picking Disorder, the APA has long ignored Olfactory Reference Syndrome, which the proposed new DSM-5 perfectly describes as “preoccupation with the belief that one emits a foul or offensive body odor, which is not perceived by others.”  And like Skin Picking Disorder, the main problem is that the APA is planning to list ORS in the Appendix for Further Research.  We have treated many people with this condition over the years, and it is clearly an Obsessive Compulsive Spectrum Disorder with a strong anxiety component.  As such, it belongs in the new Anxiety and Obsessive-Compulsive Spectrum Disorders category.

The above are just a few of the many changes proposed by the APA for the upcoming revision to the DSM.  There are many other changes related to conditions that are not directly associated with OCD or other anxiety-based conditions.  The APA is accepting comments on the revisions until April 20, 2010.

•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.

When the part of the brain responsible for making humans feel “sure enough” fails to kick into gear on its own, those with OCD and related anxiety-based conditions often use compulsive strategies to artificially create this sense of certainty. While this temporarily provides some assurance, the joy is short-lived, replaced by an overwhelming and seemingly unfair demand for re-assurance. As a strategy for suppressing the occurrence and effects of an obsession, reassurance seeking is a compulsion commonly employed by virtually all OCD sufferers, as well as those with related OC Spectrum Disorders such as Body Dysmorphic Disorder (BDD), Social Anxiety (Social Phobia), and Hypochondria (Health Anxiety).

The Problem with Reassurance

So why is reassurance such a big deal? To put it in clinical terms, when an individual seeks reassurance, they reinforce that they are unable to tolerate the discomfort of the uncertainty they are experiencing. At the same time, they reinforce that the best way to alleviate the discomfort of that uncertainty is to compulsively seek reassurance.

Concurrently, reassurance as a behavior sends the message to the brain that whatever unwanted thought set these events into motion must be terribly significant.  “If he goes through all of this just to know for sure, then this thought must be really important!”

Finally, reassurance is addictive. If reassurance were a substance, it would be considered right up there with crack cocaine. One is never enough, a few makes you want more, tolerance is constantly on the rise, and withdrawal hurts. In other words, people with OCD and related conditions who compulsively seek reassurance get a quick fix, but actually worsen their discomfort in the long term.

Three Types of Reassurance

For those with OCD and related conditions such as Body Dysmorphic Disorder,  Social Anxiety, and Hypochondria, reassurance seeking comes in three forms:

• Self reassurance. For individuals with OCD, the most obvious form of self reassurance is an overt checking compulsion, such as checking a door to ensure that it is locked.  Other less noticeable forms of self reassurance might include mentally reviewing an event or doing “mental compulsions”, such as such as repeating a “good” thought to ensure that a “bad” thought won’t come true. For someone with Social Anxiety, self reassurance might involve repeatedly doing a “mental review” of their performance at a party. For the person with BDD, a common type of self reassurance is body checking, wherein they compulsively look at themselves in the mirror in an attempt to get reassurance that they look OK.

• Reassurance seeking from others. Those with OCD and related conditions often ask others if things are OK, or manipulate others into telling them that things are OK. For example, a person with OCD may compulsively ask friends and family if they have washed their hands enough, or if they have run someone over with the car. Likewise, someone with Body Dysmorphic Disorder (BDD) may repeatedly ask others about their appearance, while someone with Hypochondria may compulsively ask family members about symptoms of certain medical conditions.

• Research reassurance. Individuals with OCD and related conditions frequently look for evidence online or elsewhere in an effort to prove to themselves that things are OK. One common example of this is what is colloquially known as Cyberchondria, wherein those with Hypochondria compulsively search the internet in an attempt to get reassurance they do not have a specific disease.

Managing the Urge to Seek Reassurance

Self-reassurance is the hardest of these to contend with because, like so many symptoms found in OCD and related conditions, these compulsions often go un-noticed until after they’ve been committed. Behaviorally, your best bet is to acknowledge the reassurance as soon as you notice it, and to stop it as soon as you can. Also, using Cognitive Behavioral Therapy techniques such as mindfulness and acceptance (the healthy practice of acknowledging and accepting thoughts and feelings without evaluating them or acting on them), one can learn to have an uncomfortable thought or feeling without over-valuing it or over-responding to it.

Resisting reassurance seeking from others often involves psycho-education of those who are most often on the giving end. Like the enabler to the alcoholic or drug addict, your loved ones might have a low tolerance for seeing you in pain, so they give you what you demand of them – even if it may actually hurt you in the long run. Consider your intent when asking for reassurance. Is your goal to remind yourself of what you already know? Is your goal to reduce your anxiety about something? If the answer to either of these questions is “yes”, then it’s best to resist asking for reassurance and to instead practice tolerating the discomfort.

Furthermore, be on the lookout for your own crafty manipulations. The word “manipulation” has a sinister connotation, but all it really means is the influencing of your environment to provide desired results. For example, merely mentioning the issue of toaster oven safety may be a not-so-subtle attempt to get reassurance, serving the same function as overtly asking if you really did turn the oven off.

One thing that seems to be very helpful with family members and partners is the formation of a reassurance contract. Simply put, the person with OCD or a related anxiety-based condition gives permission for their loved one to refuse reassurance or to reduce it to a bare minimum. When the individual asks for reassurance, the family member participating in the contract can say something like, “Remember you asked me to help you, and that means I can’t answer this question. Now let’s go do something else…”

Finally, when it comes to resisting the wealth of information (and misinformation) available from the web and other sources, it’s best to turn the computer off altogether when you find yourself just wanting to know something “for sure.” In fact, there’s no time like the present…so let’s see if you can move on from this blog without knowing for sure if you fully understood it.

•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.