EMILY ANDERSON, PHD CHRISTEN SISTRUNK, MA, LPC NAOMI ZWECKER, PHD JENNIFER SY, PHD JESSICA GERFEN, PHD - HOUSTON OCD PROGRAM
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Emily Anderson, PhD
Christen Sistrunk, MA, LPC
Naomi Zwecker, PhD
Jennifer Sy, PhD
Jessica Gerfen, PhD
What are “unacceptable thoughts”? Experienced as unwanted and intrusive Often sexual, violent, or blasphemous in nature Trigger anxiety, guilt, and shame
Sexual thoughts Thoughts about having sex with or thinking sexually about inappropriate people or things Thoughts to “go ahead” and do something sexually inappropriate Thoughts about sexual orientation
Violent or aggressive thoughts Thoughts or mental images of hitting, stabbing, strangling, or mutilating people, animals, or yourself Thoughts or urges to do “antisocial” things Thoughts of becoming a serial killer (or “what if I am a serial killer?”)
Blasphemous thoughts Thoughts against God Sexual thoughts or images about religious figures Thoughts about desecrating or disrespecting religious symbols or objects Thoughts that you have sinned, disappointed God, or behaved immorally
Rituals You Can See Physical or Behavioral (overt) Rituals - Checking - External prayer - Reassurance seeking from others - Repeating actions to undo intrusive thought
Rituals You Cannot See Mental(covert) rituals to neutralize the discomfort caused by unwanted thoughts - Internal praying - Mental checking, reviewing, reassuring - Pushing away/ thought suppression - Undoing intrusive thought with a good thought - Body checking
Avoidance behaviors Avoiding anything that triggers obsessions People Photos TV shows, movies, nightly news Books, articles, etc. Religious services
How common is this type of OCD?
Many fear that this type of OCD is rare, which only
reinforces the feeling that it is “weird”
1-3% of the population have OCD (3-9 million)
25-40% (or possibly more) have “unacceptable
thoughts” OCD
1.2 million people in the U.S. likely have
“unacceptable thoughts” OCD (750,000-3.6 million)Why do we have these thoughts? Everyone has intrusive thoughts OCD attacks the things you love or value the most If it’s really important to you to be a good person… If you really care about someone or something… Finding a thought to be unacceptable gives it more power
Why Me?!
It’s not just you! Everyone has intrusive thoughts/unacceptable thoughts
We can’t control our thoughts!
We have an estimated 50,000 – 70,000 thoughts
per day
Thought content is linked to emotional state,
environment (what we see, hear, smell), memories
Our brains are hard wiredBut my thoughts aren’t normal…
”Normal” people don’t think about this
kind of stuff!
Unwanted intrusive thoughts are common in over
80-90% of the population (Rachman, 1978)
The content of OCD thoughts are the same as
non-OCD thoughts (Rachman & deSilva, 1978;
Morillo et al. 2007)
Even clinicians can’t tell the difference!What makes my thoughts so
powerful?
When OCD isn’t present, people forget they ever had
the unwanted thought shortly after it occurs
How OCD evaluates the thought:
OCD misinterprets the thoughts as “dangerous”
OCD attaches more meaning to the thoughts
OCD attaches greater feelings /negative emotion to the
thought
OCD makes us hypervigilant for negative/unacceptable
thoughts…which increases their frequencyOCD increases feelings of “punishment”
associated with unacceptable thoughts
“That was a strange thought” vs. “I shouldn’t have
allowed myself to think about that!”
“That thought was out of the ordinary” vs. “That
means deep down I’m a horrible person “
“That thought was kind of dark, lets think about
something pleasant” vs. “ I have to make sure I didn’t
truly want to harm them…I couldn’t handle it if there
is even a chance I would have enjoyed hurting them”What I have learned about intrusive
thoughts following treatment
Intrusive thoughts are a part of everyone’s life. They
are not dangerous and do not hold special meaning.
Others understand intrusive thoughts and in many
cases have experienced/can relate to them.
My thoughts weren’t unusual. Many people had similar
intrusive thoughts.
Suppressing/trying to control your thoughts isn’t
working!
It’s time to try another strategyThought Control
Do NOT think about it
Thought suppression When you try to suppress(ignore or get rid of) an unwanted thought, it comes back with a vengeance!
Thought control is NOT possible
No one can control their thoughts, and
we don’t need to try!but HOW you
think about what
you think.Faulty appraisals It’s NOT thecontent of the obsession that is causing your distress, it’s what you believe about that obsession. Obsessions may persist because exaggerated importance is attached to unwanted intrusive thoughts.
Unwanted
Mental
Intrusion
Anxiety Trigger
Decreases/ (people, place, Faulty Appraisal/
Avoidance event) Anxiety
Negatively Increases
Reinforced
Neutralizations
&
CompulsionsFaulty appraisals From David A. Clark’s Cognitive-Behavioral Therapy for OCD Overestimated Threat Thought-action fusion (TAF) Inflated responsibility Over-importance of thought Control of thoughts Intolerance of uncertainty Perfectionism Intolerance of anxiety/distress
Your worst obsession Are you concerned that by thinking it you may be more likely to act on it [Thought-Action Fusion]? Does the obsession say something important about you and the type of person you are [Importance]? How important is it that you exercise strong CONTROL over the obsession?
Challenging faulty appraisals
Cognitive therapy
Use cognitive restructuring strategies to create
alternative, more helpful ways to think about your
obsessions
Behavioral experiments
Use mini-experiments to test the validity of your
faulty appraisalsFaulty appraisals and reframes Thought-action fusion Likelihood TAF (“If I have the obsession, then that raises the chances of the bad thing happening.”) Moral TAF (“If I have the ‘bad’ thought it makes me an immoral person and it’s the same as acting on the thought.”) Reframe: Thoughts themselves do not directly effect events in the real world. Morality is based on behavior, not thought.
Faulty appraisals and reframes Intolerance of Uncertainty: “I have to be absolutely sure about it and I must get rid of all my doubts.” Reframe: We can never be 100% sure about anything. Uncertainty is part of life and I can tolerate doubt. Trying to be 100% certain is what raises my anxiety.
Faulty appraisals and reframes Control of thoughts: “I have to control this obsession or it will control me. There will be bad consequences if I can’t control my thoughts.” Reframe: Trying to suppress and control thoughts is not possible and actually gives the thoughts more importance and associated anxiety. No one can control their thoughts.
Faulty appraisals and reframes Over-importance of thoughts: “These obsessions must be important and say something bad about me as a person.” Reframe: Dwelling on thoughts raises their perceived importance. This obsession catches my attention because it is so foreign to my actual beliefs and values.
ERP for Unacceptable Thoughts
Review of OCD Obsessions Intrusive, repetitive thoughts or images Unwanted, distressing Compulsions Usually performed in response to an obsession Aimed at preventing harm or reducing distress Not necessarily connected in a realistic way
What is ERP?
Components of Exposure and Response
Prevention (ERP)
Exposure to stimuli that produce obsessions and
fear (face fears)
Prevention of rituals to allow for extinction
(reduction) of fearHow does it work?
Promotes extinction
Negative reinforcement of escape/ avoidance from
feared stimulus (trigger) no longer occurs
Modifies mistaken thought processes (e.g., “my
anxiety will persist forever”, “Something bad will
happen if I do not ritualize”)Within session habituation
10
Anxiety 5
Level
0Between session habituation
10
Anxiety Session1
Level 5 Session 3
Session 5
0Hierarchy development Based on obsessions and compulsions, generate list of exposures Physical stimuli and situations that provoke anxiety Thoughts/images that provoke anxiety Must include person’s worst fears Assign a SUDS rating to each exposure Rank order from least anxiety-producing to most anxiety-producing
In vivo exposures
Generally begin with item that creates moderate level
of anxiety
Keep attention focused on feared situation
Focus on thoughts, feelings, physical sensations,
expected consequences
Avoid reassurance, relaxation, distraction, etc.
Continue until there is evidence of habituation
50% reduction in discomfort from peak levelsImaginal exposures Directly confront distressing thoughts, images or impulses (e.g., images of stabbing a loved one) Used to augment situation exposure; visualize the feared outcomes (e.g., use the knife and then imagine stabbing someone) Visualize confronting a feared stimulus to get oneself ready for in vivo exposure
Goals of ERP Goal is not to get rid of all bad thoughts Goal is to accept thoughts, pay less attention to them Stop efforts to fix thoughts/make up for them Externalize thoughts, correct interpretations
Let’s Brainstorm!
Treating unacceptable
thoughts
Engage in behaviors that trigger bad thoughts
(e.g., being around family and knives)
Look at pictures that trigger
Watch movies or TV shows that trigger
Go to places that trigger
Write words that trigger
Write sentences of bad thoughts repeatedlyTreating unacceptable
thoughts
Imaginal script
Script includes what you are doing, thinking, feeling,
what others are doing, the bad consequences, how
you react to them
Taped or written
Look out for rituals/avoidance
Closer to worst fears=better exposureYou can also read
