Sarosh Motivala, PhD 8/26/24 Sarosh Motivala, PhD 8/26/24

Why Intensive Treatment for Obsessive-compulsive and Anxiety disorders works

There was a time when successful treatment of OCD was considered almost impossible. In his summary of the current state of OCD treatment in 1960, psychiatrist Charles Breitner (1960) wrote “most of us are agreed that the treatment of obsessional states is one of the most difficult tasks confronting the psychiatrist and many of us consider it hopeless”.

The origins for ERP wind their way all the way back to Pierre Janet, a French psychologist and neurologist and contemporary of Sigmund Freud. Janet coined the term “exposure” and used it to describe a process in which he repeatedly presented individuals with challenging stimuli and used encouragement and firmness to promote more helpful responses to these challenging stimuli. As the story goes, Janet became a celebrated psychologist, becoming chair of the psychology department at Sorbonne, doing research in a number of areas and publishing numerous influential papers. But his work on exposure therapy did not fare as well and it took the blossoming of the behavior therapy movement in the 1960s to revive and re-interpret Janet’s work. In the late 50’s and early 60’s, researchers and clinicians struggled with treating individuals with OCD. The Australian psychologist Joseph Wolpe was a pioneer in the application of learning theory to individuals with chronic anxiety. At the time, the field of behavior therapy was growing and spreading and Wolpe’s work was instrumental in establishing behavioral treatment and exposure (specifically something called systematic desensitization). But early attempts with OCD did not yield much success until Victor Meyer, a British psychologist and former fighter pilot published a case study report of his work in a psychiatric hospital, in which he actively enlisted nursing staff to help OCD patients to prevent doing compulsions (Meyer 1966).

Some time after Meyer, other the research labs led by Stanley Rachman, Paul Emmelkamp and Edna Foa started publishing studies on what eventually became called exposure and response prevention (ERP). Behavioral scientists started to migrate treatment to outpatients, typically done in sessions once a week. But relatively quickly, it became clear that daily treatment for a short period of time was extremely effective and in addition, for some patients, once a week of ERP did not seem to be sufficient (Steketee, 1987). Since those early days, intensive treatment has become a mainstay for treating OCD, yielding improvements in weeks rather than years.

A 2015 paper suggests that intensive treatment may produce stronger treatment effects than once a week treatment. Hjalti Jonsson and colleagues compared four studies that were head-to-head comparisons of intensive (5x a week) vs weekly treatment. Each of these studies standardized the number of treatment hours so that every patient got the same number of treatment hours. But some got them in an intensive/daily format, and some got them once or twice a week spread out over an extended number of weeks. Their findings show a significantly stronger treatment effect (also called effect size) for intensive treatment.

Why might this be? Perhaps practicing learning new skills (like how to manage overwhelming anxiety) is well suited for frequent “squeezed together” practice, rather than practicing in spread out sessions. Keep in mind that spaced, weekly sessions can help considerably, but working in a concentrated fashion might be even better.

References

Breitner, C. Drug therapy in obsessional states and other psychiatric problems. In Diseases of the Nervous System. 1960 Vol 21, pgs 31-35.

Emmelkamp P & Rabbie, DM. Psychological treatment of obsessive-compulsive disorder. Book Chapter in Biological Psychiatry. 1981

Foa, E. Steketee G., and Ozarow, BJ. Behavior Therapy with Obsessive-Compulsives. In Obsessive-Compulsive Disorder. 1985, pgs 49-129.

Jónsson H. and colleagues. Intensive cognitive behavioural therapy for obsessive-compulsive disorder: A systematic review and meta-analysis. In Journal of Obsessive-Compulsive and Related Disorders. 2015 Vol 6, pgs 83-96.

Marks, IM, Hodgson, R, & Rachman, SJ. Treatment of Chronic Obsessive-Compulsive Neurosis by in-vivo Exposure A Two-Year Follow-up and Issues in Treatment. In The British Journal of Psychiatry. 1975 Volume 127, Issue 4, pgs 349-364.

Meyer V. Modification of expectations in cases with obsessional rituals. In Behaviour Research and Therapy. 1966 Vol 4, 273–280.

Steketee G Behavioral Social Work with Obsessive-Compulsive Disorder. In Journal of Social Service Research. 1987 10:2-4, 53-72

Sarosh Motivala, PhD 9/23/22 Sarosh Motivala, PhD 9/23/22

A Primer on Panic Attacks

Treating Panic: Why it all started in the 80's

The 1980’s were the beginning of the “glory years” of cognitive-behavior therapy (CBT), in my humble opinion. After slow and steady advances in conceptualizing and treating panic, in the 1980’s, our understanding of panic really came together, especially in the CBT world. To understand modern approaches to treating panic, I’m going to walk you through some of the classic CBT texts on panic to show you how CBT researchers and practitioners developed the rationales and approaches that are now so commonly used. The foundational texts were written in the 80’s and as you may or not know, I love the 80s. So I am going to pepper this text with a few non sequitur references to that great time.

But first, let’s start in antiquity. Around 2000 years ago, around the “0080’s”, Epictetus, the Greek Stoic, when faced with racing, disturbing thoughts, advised us to say to that thought: “Impression, wait for me a little. Let me see who you are and what you represent. Let me test you”*. We learn by testing things out, by investigating, by becoming familiar with that which we fear. In the 8th century the monk Shantideva wrote a crucial Buddhist text called The Guide to the Bodhisattva’s Way of Life and in it he produced a similar sentiment as Epictetus in an even more pithy form by stating “everything is made easier through acquaintance”. At the heart of treating panic, and honestly treating all anxiety struggles, is acquainting with that which is feared.

Treatment of panic involves four major parts. The first part is education about emotions, thoughts and thinking and behaviors related to panic and the panic cycle. The second part involves working on cognition - reappraising the beliefs and ways of thinking that transmute body sensation anxiety into a panic attack. The third is interoceptive exposure - engaging with body sensations that you fear may cause panic. The fourth major part is real world exposures - engaging in environments that you fear may cause panic.

Cognitive-behavior therapy (CBT) has a history of relying on clinical and cognitive neuroscience and behavioral clinical trials to develop and test treatment approaches. Early outcomes from clinical trials have indicated that the fundamental strategies to treat panic involve: teaching individuals about the cycle of anxiety and panic, breath work, cognitive reframing, and relaxation exercises. But perhaps the most important treatment strategy is directly connecting with that which you fear. In clinical terms, we call this exposure therapy (I prefer the term “engagement” rather than exposure, but I’ll save that for another post). There are two general categories of exposure therapies - in vivo and interoceptive. In vivo exposure is just another way of saying engaging “in the real world” rather than while sitting in a therapy office. If your panic attacks tend to happen when you go to shopping malls or movie theaters, then treatment involves progressively working your way up to going to shopping malls to go to the Wherehouse to buy a “compact disc” of Freddy Mercury and Queen’s new album or a movie theater to see Ferris Beuller or Pretty in Pink (sneaky 80’s references). Interoceptive exposure refers to deliberately inducing in a progressive manner, unpleasant sensations (rapid heart rate for example) that might be related to triggering panic.

Education

Education, often called psychoeducation, is a primary treatment tool in all psychotherapy, but it is particularly important in CBT. Education about panic involves learning about anxiety on multiple levels - cognitive, emotionally, behaviorally, physically/biologically and also situationally. In CBT, psychoeducation often involves some discussion of the basics of learning. How do we learn to fear things and how do we learn to not fear things?

Reworking Beliefs and ways of thinking

Clark’s cognitive model of panic (1986) introduced a central term in the conceptualization of panic that emphasized cognition, or “thinking” in the development and in the treatment of panic. Clark emphasized that an essential piece in the cycle in of panic is a misappraisal of the meaning of a body sensation as being “catastrophic”. Clark starts by saying that panic can be induced physiologically through things like infusions of lactate or isoproterenol, inhalation of carbon dioxide or through voluntary hyperventilating. Clark then notes that these things rarely produce panic in people who do not have any history of panic attacks. He then suggests that it may not be the substances or activities themselves that induce panic symptoms, but the way the person psychologically interprets the meanings and implications of the symptoms they feel when intaking these substances or engaging in these activities. Clark states that some individuals tend to interpret unpleasant body sensations (dizziness, palpitations, shortness of breath) as having considerably more ominous or dangerous meanings that they actually do. Next, these folks intentionally or unintentionally engage in behaviors that amplify anxiety. Typically these behaviors include hyperventilating, repeating overthinking and focusing on symptoms of anxiety. This then loops back to the misinterpretation of the danger of these symptoms which then circles back to the “igniting” behaviors. This looping then leads to panic. What made Clark’s model so compelling at the time was the primacy of the interpretation of these bodily sensations as being catastrophic. This gave CBT therapists an “intervention point” - to focus on helping individuals become aware of these interpretations and then helping their clients re-interpret the meanings of these symptoms. Before this, psychotherapists tended to focus exclusively on helping clients seek insight into interpersonal relationships and early childhood as a treatment approach for treating panic. It’s hard to not over emphasize how revolutionary this way of thinking was for treating panic disorder.

Interoceptive Exposure

At almost the same time, another blockbuster paper came out written by David Barlow and his team and included exposure therapy into panic treatment (Barlow et al 1989). His team’s approach integrated Beck and Emory’s approach to treating anxiety by focusing on re-evaluating on cognitive appraisals, predictions and prescriptions about self, handling anxiety and anxiety-triggering situations. They emphasized teaching clients to use tools like analyzing faulty logic, reattribution and reframing, exploring alternative beliefs, practicing decatastrophizing, and using hypothesis testing in anxiety triggering situations. All bedrock strategies in CBT.

But Barlow also speculated that panic attacks were a learned response conditioned automatically through associative or Pavlovian conditioning and operant conditioning. Simply put, in the process of living life and having distressing experiences at times, benign or mild body sensations (like dry mouth, mild dizziness, stomach tightness) and/or external stimuli like a busy crowd at a mall become paired with a danger signal + panic response. Over time, these body sensations become a conditioned trigger for panic. For example, imagine you are at Starcourt mall (or in my case, the Glendale Galleria), walking to Hot Dog on a Stick to get their giant fresh lemonade (sneaky 80’s references) and you feel flush or dizzy. Why do you feel this way? Because it happens sometimes. You get up too quick, you are little dehydrated, or maybe you are just prone to mild dizziness. But automatically, you start to feel anxious because that sensation might remind you of a panic attack you had. The anxiety builds, you might even start focusing on “what if I have a panic attack right here right now in from of all these people? This could escalate into a full blown panic attack, or you might leave the mall to prevent a panic attack. This pattern of behavior strengthens the relationship between the sensations, the mall and a panic response.

Barlow and colleagues emphasized repeated exposure to these benign physical sensations that arise early on before a full blown panic attack develops as a way to help the body “relearn” that these sensations are normal and do not need to trigger a panic attack. These techniques involved “bringing on” specific physical sensations related to panic - like hyperventilating for 30-60 seconds to bring on rapid breathing or doing jumping jacks to bring on a sensation of elevated heart rate. They coined the term interoceptive exposure as a technique in which the therapist leads the client through a set of exercises meant to stimulate these physical sensations. By repeatedly practicing engagement with these sensations, clients begin to learn to break the chain linking these sensations to the onset of panic.

There are a variety of exercises that fall under the umbrella of interoceptive exposures and cover intentionally produced body experiences such as dizziness, shortness of breath and rapid heart rate. Lee and colleagues (2006) broke down these exercises into four categories: neurological, gastrointestinal, cardiorespiratory and dissociative. In his book on panic disorder (Taylor 2000) Steven Taylor compiled a list of 17 exercises such as spinning around while standing up with arms stretched for 1min, breathing through a narrow straw without breathing through your nose for 2 min, etc. These exercises are typically of a short duration and are practiced in session 2-3x during a session and then practiced at home 3-5x a week. Before engaging in these exercises, a client is asked what their beliefs are about triggering these sensations (I will not be able to handle it, I will be anxious for a long time afterwards, etc). Then by deliberately engaging in the triggering behavior, the client gets to experience an “expectancy violation” - i.e. the bad event either didn’t happen, or was less intense than expected, or was very intense yet the client learned to manage them. This produces new associations and new ways of thinking about the triggered sensations either automatically or through debriefing conversations with the therapist.

Real world Exposure

Reintegrating into triggering situations is the last major aspect of panic treatment. Where do people experience panic? In their bedrooms? In their cars? In restaurants? How can we help people work on getting back to being in these situations?

Real world exposures are conducted via a road map - a hierarchical listing of situations ranked in increasing distress intensity, with the most triggering situations listed at the top and the least triggering situations at the bottom. Therapist and client work together and start at the middle or lower middle of the list. Either in session or as homework the client practices being in those situations. Real world exposures are challenging - there are alot of variables at play. But they can be very helpful to clients. Therapists who work within the Acceptance and Commitment Therapy (ACT) framework of CBT prefer to scrap the hierarchy of feared situations and instead develop a listing of desired behaviors (going to a movie, taking a flight somewhere) and creating a roadmap to help the client engage these behaviors in those situations and not avoid being in situations they want to be in. ACT therapists emphasize that the most important factor in real world engagement is the desirability of being in the situation (“it’s important to me”) rather than the degree of distress the situation might trigger.

There is some indication that real world exposures are useful, but are NOT as essential to successful treatment as interoceptive exposures. Craske and colleagues (2006) compared interoceptive exposure treatment versus interoceptive + real world exposure treatment and found that the reductions in panic attacks were similar for both groups. Alessandro Pompoli and Toshi Furukawa (2017) published a review of 72 studies with a total 4064 patients with panic disorder. In their statistical review of these studies, Pompoli and Furukawa found that interoceptive exposure treatment had better outcomes than real world exposure treatment.

So, if you are getting treatment for panic, one take home message is that doing interoceptive exposures is very helpful and that doing real world exposures may be helpful, but you need to do the interoceptive exposures as well.

What about breath work or muscle relaxation? It works, people like it, but it doesn’t work as well as exposure.

Remember 5-4-3-2-1 breathing? Google panic treatment and you will find lots of write ups about how to do it. It seems like a reasonable idea that teaching people to slow their breath or to relax would be a useful technique for helping people with panic. Early treatment studies done in Barlow’s lab compared relaxation training versus cognitive therapy + exposure training (Barlow 1989) and found that both were clinically helpful in reducing panic attacks. But they noticed that cognitive training + exposure therapy group had a larger number of people reporting having zero panic attacks in the period after treatment was complete. Plus, a 2 year follow up study with the same sample found that the benefits of relaxation training did not hold up well over time, but the benefits of cognitive training + exposure training held up remarkably well and actually improved over time (Craske et al, 1991). This framed relaxation techniques as helpful but limited. These studies were ground breaking at the time but had very small sample sizes. Since those studies, many, many clinical trials seem to indicate the same thing. In the review analysis done by Pompoli and Furukawa (2017) examining 72 separate studies on panic disorder treatments, they found some interesting results on breathing retraining and muscle relaxation. They concluded that education, cognitive training and exposure therapy, specifically interoceptive exposure, were the best CBT strategies to use in terms of symptom reduction and remission rates and that muscle relaxation and breath focused strategies were the “least helpful” strategies for treating panic attacks. Yet they found that study participants liked having breathing retraining exercises to practice. So breath work helps, but not as much as you’d think, but people like doing them. So about 30 years after Barlow and Craske’s initial small pilot study findings on treating panic have held strong. Sorry to sound repetitive, but it will really help to do the interoceptive exposures. Don’t skimp on them!

The take home message

The 1980’s gave us the Showtime Lakers, Prince, Madonna, and fabulous fashion (remember Kajagoogoo and Spandau Ballet?). It also gave us the foundations of CBT based panic treatment and in the ensuing years, through a number of clinical trials and basic science studies have spelled out the important components of treatment. Psychoeducation, reworking how you interpret body sensations that are unpleasant and associated with panic, and interoceptive and real world exposures. Each component involves learning - learning about how our body learns to react with panic and perpetuate avoidance behaviors that strengthen the panic cycle (Barlow 1989), learning about the roles of cognitive appraisal in the panic cycle and how to work on it in treatment (Clark, 1986) and how engaging in exercises that trigger body sensations associated with panic helps our body learn new ways to handle these sensation instead of trying to escape or avoid them.

References

Alessandro Pompoli et al 2017. Dismantling cognitive-behaviour therapy for panic disorder: a systematic review and component network meta-analysis

Barlow 1989. Behavioral treatment of panic disorder

Clark, 1986. A cognitive approach to panic

Craske, Brown & Barlow 1991. Behavioral treatment of panic disorder: A two-year follow-up -

Craske, DeCola, Sachs, Pontillo Panic control treatment for agoraphobia

Taylor 2000. Understanding and Treating Panic Disorder: Cognitive-Behavioural Approaches. Link to the Book

* I read the Epictetus quote was in an excellent book by Donald Robertson called The Philosophy of Cognitive-Behavioural Therapy.

Sarosh Motivala, PhD 9/23/22 Sarosh Motivala, PhD 9/23/22

A History of Panic Disorder

Panic has been with us for very a long time. The very first known work of literature, The Epic of Gilgamesh, about four thousand years old, recounts King Gilgamesh’s struggle with panic and fear of dying, which then triggers his quest for immortality (spoiler alert: he fails at this) and also for the meaning of life (he has success on this front). My quest is more modest - to walk you, the reader through the evolutions of conceptualizing the panic experience.

The language, terminology and theoretical conceptualizations have evolved over time from the 18th century conceptualization of panic due to toxic vapors emanating from the uterus, to panic stemming from psychological neuroses, to more recent cognitive-behavioral theoretical models of panic (see my write up). Modern descriptions of panic symptoms from the Diagnostic and Statistical Manual Version 5 include:

intense fears of losing control or going crazy

intense fear of dying

palpitations, pounding heart or rapid heart rate

chest pain

feeling short of breath

nausea or stomach distress

dizziness

sweating

trembling

chills

numbness or tingling

derealization

How Panic got it’s name

Panic disorder wasn’’t conceptualized until the third version of the Diagnostic and Statistical Manual (DSM-III) in 1980. But to get to that more modern conceptualization, let’s first go to 1771. French physician Boissier de Sauvages wrote the Nosologie Methodique, a comprehensive catalogue of all the known diseases of the time in Europe (Weckowicz, & Liebel-Weckowicz 1990). One set of disorders he describes is something he called “panophobias”. By combining pan with phobia, he coined the term panophobia, literally meaning a “fear of terror”, or “a fear of fear”.

Why “pan” and “phobia”? Where do these terms come from? Pan was a Greek forest deity with goat legs and a human body who screamed loudly and wildly at humans whenever they wandered through his territory. Pan is a curious choice to name panic after. Personally, I don’t get it. He may have freaked people out with his screaming, but he also played the flute really well (“the Pan flute”) and rather than looking fearsome, in some depictions Pan looks downright handsome, like a sexy Sasquatch.

The term phobia comes from Phobos, another Greek god, this one being who the son of the war god Ares (also known as Mars). Phobos used lightening and thunder to paralyze people with fear, especially soldiers before a battle. Asaph Hall was a cheeky astronomer who discovered two moons revolving around Mars and decided to name one of them Phobos. So when you gaze up at the red planet named after the god of war, look for a tiny little moon named after the god of fear. Sadly Martian Phobos doesn’t look as beautiful as our own moon, and in my humble opinion it resembles a Russet potato.

Let’s get back to our good French doctor. In his book Boissier de Sauvages identified a sequence of different panophobias, but one resembles what we’d call modern day panic: panophobia hysterica. This was a disorder whose typical symptoms involved intense fright, dramatically increased heart rate, and clamminess. But strangely, Boissier de Sauvages as well as a number of physicians at that time believed that panophobia hysterica was caused by “vapors”. They were not referring to the famous rock band from the early 1980’s, but to vapors that escape from a person’s uterus and toxify other parts of the body. Boissier de Sauvages provided one of our earliest modern definitions of panic, but his explanation as to why they occurred was off the mark.

In Europe in the 1800’s there was a explosive growth in the sciences - arguably culminating with the works of Darwin and Wallace. Robert Koch published works on infectious diseases and spurred on scientists to look for biological and microbiological causative agents of disease. In the psychological sciences, research psychologists like William James were just getting cooking in America. In Germany, psychiatrist Emil Kraepelin, considered one of the founding fathers of modern psychiatry, put forth the idea that mental illness is biologically and genetically driven. Kraepelin did not describe panic as a separate disorder, but he did describe symptoms of panic that were embedded into a variety of diagnoses, especially bipolar disorder (at the time called manic depression). Contemporaries of Kraepelin, like Freud and Janet also started describing anxiety in newer ways, leaving the vapors idea behind. Freud tried to separate anxiety from an “anxiety attack” that he described as having a stronger physical presentation. After the vapor induced panic of the 1700’s, the panic of the 1800s integrated biological and psychosocial pathways but panic itself still did not get much attention on its own, but as part of other diagnoses.

Panic as an “anxiety neurosis”

Now, we come to America, specifically New York and 1917. The National Committee for Mental Hygiene and the American Medico-Psychological Association (which would eventually become the American Psychiatric Association) came up with the Statistical Manual for the Use of Institutions for the Insane. The steering committee that worked on the book was chaired by Albert Barrett, a psychiatrist who trained in Heidelberg with Kraepelin. The book was for physicians who worked in asylums and so it emphasized severe mental illnesses that necessitated hospitalization. The book was also a precursor for the DSM that would be published in 1952.

The book primarily focused on psychotic symptoms, but under the term “psychoneuroses”, they did describe four types of neuroses, the last of which was called anxiety neurosis. This included “morbid fear as the most prominent feature…as well as numerous physical symptoms which may be regarded as the bodily accompaniments of fear, particularly cardiac and vasomotor disturbances: the heart’s action is increased, often there is irregularity and palpitation; there may be sweating, nausea, vomiting, diarrhea, suffocative feelings, dizziness, trembling etc”.

At this point, you might be asking where is the science? Lots of very wise clinical judgment at work in conceptualizing things, but we need the science. After all, we are in the early 20th Century at this point in our journey. Looking at other disciplines, by the 1950’s infectious disease scientists were expanding the basic concepts of the scientific method to develop and test vaccines - so much so that by 1954, double-blind clinical trials were being done with 1.8 million children to test the effectiveness of the polio vaccine. What were psychologists and psychiatrists up to? Well, just a little more patience.

In 1952, the American Psychiatric Association published the first Diagnostic and Statistical Manual, Version 1 (DSM-I) but STILL no formal diagnosis of panic existed in it, instead they used the term psychoneurotic disorder to describe panic-like symptoms. This first version of the DSM was heavily influenced by ideas presented by Freud, Kraepelin and others.

Panic as an official disorder

In 1972 Feighner, Robins and colleagues published “Diagnostic Criteria for Use in Psychiatric Research” which substantially altered the way in which we diagnose psychological disorders (it has been cited over 7000 times in other scientists’ papers). Feighner and his coauthors argued for information from clinical studies to be included in how we conceptualize each disorder. They emphasized statistical concepts like validity and reliability as guide for diagnostic criteria. This reflected a shifting perspective away from relying exclusively on clinical observation and judgement to including results from empirical studies. This might seem obvious in today’s world, but it wasn't back in the day.

Finally, it wasn’t until 1980 (the year the 80’s band the Vapors had their biggest album - remember them?) that the DSM-III was published and debuted the diagnosis of panic disorder. The DSM-III formally separated the terms anxiety and panic into separate diagnoses. Before the 80’s were over, Behavioral scientists would publish comprehensive conceptualizations of how panic disorder may develop and present itself as well as treatment approaches that are still used to this day.

References

Craddock N, Owen MJ. The Kraepelinian dichotomy - going, going… but still not gone. Br J Psychiatry. 2010 Feb;196(2):92-5.

Kawa & Giordano, 2012. A brief historicity of the Diagnostic and Statistical Manual of Mental Disorders: Issues and implications for the future of psychiatric canon and practice

Nardi, 2006. Some notes on the historical perspective of panic disorder.

The Vapors They are still touring. Get their merch and tour info here at www.thevapors.co.uk

Weckowicz & Liebel-Weckowicz. A History of Great Ideas in Abnormal Psychology

Sarosh Motivala, PhD 12/13/21 Sarosh Motivala, PhD 12/13/21

Through a mirror, darkly. Understanding Body Dysmorphic Disorder

What does it mean to be seen? How do we perceive our own appearance? How accurate is it? When I look at myself, am I really seeing what you see when you look at me? Is a photograph or a reflection in a mirror a real depiction of someone’s face? Is beauty or attractiveness objective? Is it subjective? A combination?

Misunderstood, under diagnosed and not properly recognized, Body Dysmorphic Disorder (BDD) is a difficult diagnosis. It involves an intense, repetitive focusing on a specific part of one’s body combined with the perception that that that body area is flawed or ugly. Skin, hair and the nose are the most common areas of focus, but a person with BDD can be preoccupied with almost any body part. Over long periods of time, a person with BDD can shift their preoccupations from 6-7 different body parts (see Wilhelm, Phillips & Steketee 2013). Typically, the body part in question is not typically viewed as ugly or flawed by others, yet what can be surprising is the strength of the conviction that people have about their perceived defects. Before CBT treatment, between 27-39% of people with BDD state that they are completely convinced about their perception of is accurate and not distorted at all (Phillips & colleagues, 2008). Along with these perceptions come a time consuming or life impacting set of behaviors centering around evaluating, covering up or fixing their appearance or avoiding situations in which they will be triggered because of their appearance.

Population studies suggest a 1-2% prevalence, meaning that 1 or 2 people out of 100 currently have BDD. If you don’t think that’s a lot of people, keep in mind there are 10 million people in Los Angeles County, so that means there are probably about 200,000 Angelenos with BDD right now. Older studies done in dermatology clinics and cosmetic surgery clinics found that rates of BDD range from 9-53% of patients (Wilhelm & colleagues, 2013, pg 11) and that people with BDD can get multiple procedures done and are consistently dissatisfied with the results of those procedures.

Do we know a lot about BDD? Yes. Could we learn much more? YES! To give you a flavor for how under studied BDD is, I did a quick PubMed search on scientific papers published with a keyword of BDD and compared it with OCD and major depressive disorder.

It’s clear from the graph above there aren’t many studies BDD. From 1950-1990 there were just 39! That’s about just one published paper per year. Compare that with over 3000 published papers on OCD during the time period. That’s 10x more. And forget about the number of papers on depression; there were about 530 papers published on depression for every one paper published on BDD.

Although understudied, there are some very good studies on BDD. Modern conceptualizations of BDD probably got their start in Genoa Italy around 1891, when Enrico Morselli coined the term of “dysmorphophobia” after doing case reviews of 78 patients. He described it as a “persistent idea of deformity combined with tremendous anxiety about that awareness” (Fava, 1992). Morselli wrote extensively about dysmorphophobia but only recently has BDD been a more commonly talked about disorder. In their excellent overview, Sabine Wilhelm, Katharine Phillips and Gail Steketee write that patients with BDD “are convinced that they are physically deformed and are reluctant to initiate or stay in psychiatric treatment” and “they need more intensive engagement and ongoing motivational interventions.” (Wilhelm, Philips and Steketee, 2013).

Details vs Holistic awareness

Exactly how one comes to get stuck on a flaw in their appearance is not exactly as you would expect. The strength of the belief that one’s skin is flawed is not hallucinatory delusion, but may actually stem from a razor focused ability to notice details combined with poorer holistic visual perception. Neuroimaging studies by Jamie Feusner and his colleagues have consistently shown that people with BDD are better able to recognize facial details than comparison control participants. Early studies showed that when it came to looking at human faces, patients with BDD had left hemisphere hyperactivity in higher-order, detail specific visual processing regions compared to non-BDD control subjects and less brain activity in front-striatal visual processing areas associated with holistic, contextual visual processing of facial features. So although patients with BDD were very good at noticing facial details, they were not good at noticing “gestalt” aspects of facial expressions. Later imaging studies found that BDD patients showed the same pattern even when not looking at people but at pictures of houses. Good at noticing details, not good at noticing the big picture.

CBT for BDD

Wilhelm and colleagues outline a treatment approach for BDD that has four core interconnected parts: awareness of maladaptive beliefs, exposure and response prevention, perception retraining, and reworking problematic deeper held beliefs about the self. In our approach at Spectrum CBT we promote and prioritize an essential additional piece which is a focused examination of the behaviors and habits involved in thinking. So not just what you believe, but what and how you think about things in your daily life.

Awareness of maladaptive beliefs

Each of our minds are so active, so talkative, that what we see, hear, touch and taste is an augmented reality. Our sensory experiences of people’s smiles, the shapes of their eyes and the sounds of their voices are augmented with memories, stereotypes, reminders, agendas. Our mind refashions sensory experience through our internalized anticipations, feelings and beliefs. “People often judge appearances”, “being attractive all the time is extremely important”. These beliefs color and shape our experience. So you and I could be talking and we could perceiving our conversation in very different ways.

In CBT, we like to use jargon like “maladaptive”. What this specifically means is a fusion or a pairing of two concepts: usefulness and a better approximation of realness or truth. TRUTH! It’s hard to figure out what’s really true and I’m not a philosopher, so I’m not going to spend too much time on truth. I don’t know if the X files are right. I don’t know if truth is out there. I don’t know if truth is knowable. But a foundational piece of being scientific and employing the scientific method is that there is an order to things, that through observation we can learn and improve our understanding of how things work. In CBT we apply this mindset to ourselves. There is an order to us, and we can learn and improve our understanding of we work and how others work. But more importantly, maladaptive relates to the concept of usefulness. Is this action useful? Is this thought useful? And then useful for what? Useful for keeping me miserable? Useful for helping me navigate life’s challenges? Maladaptive then are beliefs

Exposure and Response Prevention

I don’t like the term exposure and response prevention. It’s like saying “groovy”, “tubular” or “awesome”. There was a time and place for it and now it sounds old. I prefer “behavioral engagement”. How do you engage in tricky life situations? What beliefs wake up and become prominent? What habit urges kick in when you are challenged? And how can we work on shifting and improving these habit and approach styles? Through practice; intelligent, focused practice. Not haphazard, but thoughtful; not focused on flooding and overwhelming people so that their anxiety will go away, but focused on teaching people how to approach and handle situations differently so that they can work through them fluidly and much more effortlessly. Engagement is a form of learning by doing, like bike riding. You don’t read about riding a bike and you don’t talk about riding a bike. You practice riding a bike. Sometimes learning something is really hard so it helps to have someone to help you learn it. That is exposure and response prevention.

Perception Retraining

When you look in the mirror, what do you see? It should be an easy answer. I see myself. But, that answer hides a deeper more complex answer. The real answer is, it depends.

Sometimes I see my face, sometimes I see how I have aged, sometimes I see my nose hairs, sometimes I “don’t” see my nose hairs. The act of perceiving almost seems to toggle between between a “detail” mode and a “holistic” mode. Some people may perceive faces in a more detail-focused way and others may perceive faces in a more holistic-focused way that integrates visual information and emotional expression. People with BDD seem to perceive faces in a much more visual, detailed manner (Feusner et al, 2007, JAMA Psychiatry). People with BDD also tend to view these details and then habitually compare and evaluate details of faces. You could say that having BDD involves a tendency to automatically be in detail-mode and difficulty getting into holistic mode; plus, while in detail-mode, people with BDD also view certain details (their nose, their eyes) through an evaluative good/bad filter rather than an observant, descriptive, nonjudgmental filter. A goal of perception retraining would be to help individuals practice using that non evaluative filter instead of the default judgmental filter.

Beliefs about the self

In basically any form of therapy, we bore down into the deep of who are you? Or perhaps a better way to put it is, who do you THINK you are? Often we will find that we hold some dark, problematic views of our self and BDD is an outer manifestation of that and a perpetuating cause of those dark views. So in CBT we explore what those views are. What are those core beliefs about yourself? Chances are you hold competing views of yourself (capable vs incapable; lovable vs unlovable) and sometimes the negative, nastier views of self are more dominant, more active, and are fed more “juice” than the more positive views. So can we devise mechanisms for alternative core beliefs to get some energy? To get some sunlight?

Maladaptive habit-based thinking

Thinking is complex set of mental behaviors and just like any other set of complex behaviors like walking, running, dancing, cooking, eating etc, we have the capacity (really the necessity) of chaining simple behaviors together to form a whole-integrated pattern that then becomes fluid and feels “natural”. Then this behavior set can be linked to specific cues in our environment based on location and time. As an example, at night, I develop a routine of putting on pjs, brushing teeth and reading in bed. This becomes a habit. If I deviate from the habit, I become uneasy. Habits are behaviors that stimulus triggered and produce a feeling of resolution when I complete the habit. Thinking types - reviewing, planning, comparing, explaining, problem solving can become thinking habits. Thinking habits that I do too much, do at the wrong time, or habits that I do poorly. Habits can be helpful or problematic. If someone has BDD, they probably have thinking habits that are very problematic. So part of our job is to examine what these habits are and work with a person to start deconstructing these habits and see if we can replace them with better ones.

REFERENCES

Fava, G.A. 1992. Morselli’s Legacy: Dysmorphophobia. In Psychotherapy and Psychosomatics, Vol 58.

Feusner et al., 2007. Visual information processing of faces in body dysmorphic disorder. Arch Gen Psychiatry Vol 64.

Feusner et al 2011. Abnormalities of Object Visual Processing in Body Dysmorphic Disorder. In Psychological Medicine, Vol 41.

Wilhelm, Philips and Steketee, 2013. Cognitive-behavioral treatment of BDD. Guilford Press.

Phillips, Didie, Feusner & Wilhelm, 2008. Body Dysmorphic Disorder: Treating an Underrecognized Disorder

Sarosh Motivala, PhD 6/1/21 Sarosh Motivala, PhD 6/1/21

Why video sessions work

A common and reasonable concern for people starting with us is whether remote, video sessions for psychotherapy and cognitive-behavioral therapy (CBT) in particular are helpful. It turns out there is a good amount of research on these specific questions that demonstrate that video sessions actually work very well.

In a comprehensive review of 103 research studies, Fernandez and colleagues report that “video” psychotherapy is as effective as in person therapy, regardless of the type of talk therapy (Fernandez, Woldgabreal et al, 2021); but even more that that, CBT based video therapy seems even more effective. In their paper, the study authors emphasize that video therapy seems to be particularly well suited to CBT.

In the past year, we have exclusively focused on video based CBT treatment for OCD, specifically exposure and response prevention (ERP). We regularly get phone calls and emails from people who think that remote therapy wouldn’t work well for OCD. In our experience this is not at all the case and this is consistent with published studies showing the effectiveness of remote therapy for treating OCD. Bethany Wootton published a meta analytic review in 2015 on exactly this topic. She looked at results from 18 studies and found that remote treatment (video or telephone) led to significant improvements in OCD symptoms that were similar to in person treatment.

Wootton describes a few advantages of video based CBT. The first is that distance from the office is no longer a factor. Pre 2019, it would not be usual for people to come to the clinic after an hour long drive. If you lived 2-3 hours from us, you were out of luck. I had one client whose commute time was 2 hours to come see me. Yikes!

Another important factor that is specific to treating OCD is that we get to see clients in their home environment. This can be helpful because we get to conduct exposures in people’s home. Although it’s not true for everyone, but typically OCD flourishes in the home environment so working on it directly in that environment is really useful.

A third important piece is that we get to use the computer. Spreadsheets, whiteboards, sharing documents to read over are all really useful. We can do that in person too, but via video it becomes much easier. This is really great for tracking homework in that we can mutually go over what’s working and what’s not working in terms of getting homework done.

There are downsides however. The most basic one is privacy. Some people live in homes or apartments where privacy can be difficult. Privacy is vitally important to therapy because we have to have a talking area where you feel comfortable airing things out. And some of the things you air out may not be flattering to yourself or to others. But to get some honest work done, we need to put this stuff on the table. Feeling like you don’t have a private area can pose significant problems with that. These issues often have work arounds. People can use headphones, or can ask family members to not be in the house for the hour.

Some people can get distracted doing video therapy. They get text messages, email notifications, they get tempted to surf the web. The good news is that this is workable and an assertive therapist can point out that they notice the client seems distracted. Usually calling this out a couple times does the trick.

Lastly, some folks are just not tech savvy and are not interested in becoming more video or tech savvy. Ultimately, this is understandable. It is your choice.

The COVID-19 boom in video meetings, overall in my opinion, for therapy, has forced us to invest and really try out doing video therapy and to take advantage of its unique positives it offers while also making us aware of its problems. But even before COVID-19, a number of research studies clearly have shown that video CBT works very well; in fact so well, that it should not be considered a second tier alternative to in person therapy but on par with in person therapy.

REFERENCES

Ephrem Fernandez et al. Live psychotherapy by video versus in‐person: A meta‐analysis of efficacy and its relationship to types and targets of treatment In Clinical Psychology & Psychotherapy. 2021 Apr 7. doi: 10.1002/cpp.2594.Online ahead of print.

Bethany Wootton. Remote cognitive–behavior therapy for obsessive–compulsive symptoms: A meta-analysis. In Clinical Psychology Review. Volume 43, February 2016, Pages 103-113

Sarosh Motivala, PhD 8/25/20 Sarosh Motivala, PhD 8/25/20

COVID Fatigue

Fatigue is the sibling of anxiety. Generally speaking, if you’re dealing with anxiety for an extended time (let’s say 3-4 months or longer), fatigue usually shows up at some point. Anxiety is a “go” emotion and eventually the go-go-go aspect of anxiety also comes with a slow-slow-slow aspect.

If you look up the diagnostic symptom criteria of “generalized anxiety”, a type of chronic anxiety disorder, you’ll find on the list two candidates: poor sleep (not surprising) and being easily fatigued (surprising to some people, but not to anyone who has dealt with chronic anxiety). Between 80-90% of people with generalized anxiety disorder report experiencing significant fatigue AND about 80-85% report trouble sleeping (Zbozinek, Rose, et al, 2012). So let’s establish that if you are dealing with chronic anxiety, it’s not a stretch to say you will probably be dealing with trouble sleeping and fatigue.

Initially, the changing and sometimes confusing, often stressful demands of COVID-19 could have been thought of as a short term stressor. There was a time in early April, where I was thinking this all should be over by June. Well here we are in late August, this thing just keeps going. The initial waves of stress and anxiety start to morph into chronic turbulence and when that happens, fatigue starts to play a much more prominent role.

Let’s be precise. There’s fatigue and there’s tiredness from exertion or sleepiness from poor sleep. They are slightly different. If we are talking about tiredness then rest. Take a mental health day and “chill”, unplug. If you are tired or sleepy from poor sleep during the day, then start to get your nighttime sleep routine in order. You can get some help HERE.

But if it’s stress-fatigue, here’s what it can look like. There are different kinds of fatigue, and you can feel one, some or all of them. We typically think of fatigue as being physically tired out, or a sense that you can’t take on a lot physically. Then there’s mental fatigue, that can feel like it takes a lot of effort to do things that typically aren’t that effortful like looking up a place to get take out food. Then there’s motivation level - where you just don’t feel like doing anything.

With COVID, it wouldn’t be that surprising if you not only feel physically tired sometimes, or even feel like your motivation is out the window and rolling down the street. Tackling fatigue can be tricky, but it helps to start with the basics - looking at how you are sleeping. Not just how much, but also looking at your pre-sleep bedtime routine and how fast it takes to fall asleep. How much are you waking up in the middle of the night? How restful does your sleep seem? There are good places to read about how to sleep better. You can check them out HERE. Next, look at nutrition - are you eating well? There are a variety of eating plans out there but ask yourself - does your eating pattern involve good nutritional intake? Next, you might be too sedentary. Are you exercising? If not get that mask on and go for a walk, bike ride or run and work it into a daily routine. Sometimes you could be fatigued because you are too active. Overtraining is a major cause of chronic fatigue in athletes and even though you might not be an athlete, sometimes when we are stressed out we overtrain for our fitness level and that leads to the experience of fatigue.

Mental fatigue and feeling unmotivated connect more closely with emotional regulation and this might be a good opportunity to have a discussion; with your mind and body. They are talking to us all the time but often we tune them out and don’t listen, usually because we aren’t well versed in the language of the body. Fatigue can be your body’s way of saying “something isn’t going well motivationally, emotionally, situationally”. So, get out that journal, do a contemplative meditation, share where you are at with someone you trust, or get some therapy and explore what’s going on.

Sarosh Motivala, PhD 2/25/20 Sarosh Motivala, PhD 2/25/20

Listening better

I have a habit of looking at my dog and talking in a “dog” voice. “Yum that chimkin sure lookin good”. It really gives me a lot of enjoyment. I don’t really know why. It’s a bad habit that would probably weird out any house guests that we have.

Then I discovered that there are scores of people that do the same thing and post videos on instagram about it. And, I can scroll through instagram enjoying doge memes. It’s not healthy. And lastly, I hate to admit it, but I understand why Christophe talks to his reindeer. We all are doing that stuff. There’s something completely, uniquely human about talking. I even talk to myself!

But sometimes all that talking is just too much. We are just TOO GOOD at talking. Let’s get better at listening. We could all hone our listening skills a fair bit. When people are struggling with OCD, anxiety, depression, or other mental health issues, they need to be heard. That comes first. That’s hard to do. Before advice or opinions, listening comes first. So let’s agree to prize listening; to restore its place at the center of connecting and talking to each other.

Listening well involves something obvious - hearing what people say. And something not so obvious - telling and showing the person that you hear them. Giving your attention is a precious gift! Give it generously. Some problems are not fixable, or aren’t fixable right now. That is exactly the time that we need to know we aren’t alone. We need to know that someone sees and hears us. Sees what we are going through. We aren’t struggling and suffering alone. When someone listens - I don’t feel as alone. It may not get rid of my ache, but yes, something does feel different, perhaps my ache feels more bearable.

Listening isn’t passive. It’s work! Im not analyzing or evaluating or interpreting when I am listening. I am focused, attentive. I am communicating I am listening by saying things like “Sounds like you are saying....” or “I hear you”. When we listen actively, we encourage conversation with open questions - we inquire. The vibe is gentle, and we don’t press or push. I know it sounds cliche, but I like to listen with some open questions like “when that happened, how did that feel?” Also, asking with a “how” is ALOT better than a “why”. Most of us don’t like “why did you do that?” We like “Oh no! how did that happen?” a little more. It’s hard to feel heard if I am spending time trying to defend myself.

Problem solving, blaming - do you know who did this? Sometimes we just want to figure out who screwed up. We want someone to take responsibility or the blame. That’s fine - but it isn’t good listening. If you want to getter better at listening, put the blaming hat away for a while and put on the “I hear ya” hat. Sometimes it’s a relief to just not have to talk as much. We can listen too.

Sarosh Motivala, PhD 2/21/20 Sarosh Motivala, PhD 2/21/20

Lost in the Wild

In his excellent book Deep Survival, Laurence Gonzalez writes about his studies on the experience of being lost in the wild. Hikers who lose their way experience something called woods shock; Gonzalez writes “everyone who dies (in the woods) dies of confusion. There is a destructive synergy...including exhaustion, dehydration, hypothermia, anxiety, hunger, injury.” Woods shock is a useful experience to learn about in order to better understand the very common and troubling experience of panic (click here for a more basic run down on panic disorder).

Woods shock is the catastrophic reaction people can have when they grapple with being lost. When their mental maps of their location do not match with their physical environment and when the internal tussle between reason and emotion no longer work in accord, but instead “become like two swimmers, dragging each other down.” In its worst cases, Woods shock can lead to death. I have heard time and time again that when my clients panic, it is like they are drowning and that their emotions are swirling around them with incredible ferocity.

Gonzales recounts stories of experienced hikers doing inexplicable things like not making a fire, misreading landmarks, discarding backpacks when lost. Why? Why when our reasoning faculties are needed most, do they sometime abandon us?

Disorientation

The roots of woods shock start with becoming disoriented; you lose the connection between your surroundings and your internal, mental map of your location. But plenty can happen between this disorientation and full blown woods shock. “Being lost is not a location, but a transformation” Gonzalez writes. He outlines it as follows a few poor mental strategies we use to handle being lost. A perversion in the “call to action” drives a series of mental strategies that transform being lost into being injured, making poor decisions, being hopeless. Initially a refusal to admit you are lost and a tendency to act out “convincing oneself that you are ok” leads to urgently forging onward. This denial can help us cope with the rising panic, but it eventually peters out and may even make us more disoriented. So we move on to another approach - a massive action strategy. The emergency is realized, but the response is frenetic massive action (running, fast walking). This keeps the rising panic at bay, providing a sense that “I’m on this”, but it burns precious energy and can make you vulnerable to fast but poor decision making and even physical injury (slipping, falling). After burning up your physical energy, you might switch to a cognitive strategy. Gonzalez describes it as frenetic orienting. A panicked attempt to mentally figure out where you are. The mental velocity of this state does not lend itself to accuracy, insights and realizations about where you are and what you need to do. If anything, it promotes poor decision making. It is important in these moments, to work your way to a place of acceptance/resignation AND determination. It’s a delicate balance. But important to survive.

The Split

When a person realizes they are stuck, Gonzales describes “the split”. In example after example of mountain climbers, sailors, fighter pilots lost in the wild, and I would add those that struggle with panic attacks, Gonzales writes that a person starts to split into two people - one that perceives reality and is coldly rational, and another that is having “waves of hot emotion”. This is a common experience in panic attacks - one part of my mind is freaking out, the other is rational. Understanding this split, accepting it, and working to maintain a balance between these two subjective experiences - is vital. Gonzales writes about climber Joe Simpson and his partner Simon Yates as they were descending the summer of Siula Grande, a 21,000 foot peak in the Peruvian Andes. Simpson broke his leg on the climb down. Simpson and Yates worked together to help Simpson, but both men knew that Simpson was in ALOT of trouble. Regarding the balance of his split mind, the balance between rational and emotional, Simpson writes in his book Touching the Void, “It felt as if I was holding something terrifyingly fragile and precious.”

Gonzales quotes from the diary of a sailor, Steve Callahan, who was on a solo sailing trip across the Atlantic when his boat collided with a whale and began to sink. Callahan wrote “a myriad of conversations and debates flash through my mind, as if a group of men are chattering with my skull. Some joke…others stoke the furnace of fear…I must be careful. I fight blind panic: I do not want the power from my pumping adrenaline to lead to confused and counterproductive activity. I do not want to sit frozen in fear until the end comes. Focus, I tell myself.”

Gonzales then writes that Callahan handled the split with self-talk - enacting a sense of discipline. Callahan later wrote, “When I am in danger or injured, my emotional self feels fear and my physical self feels pain. I instinctively rely on my rational self to take command over the fear and pain.” This to me is, is a vital, beautiful statement to remind ourselves of when the panic storm is raging.

Sarosh Motivala, PhD 10/31/19 Sarosh Motivala, PhD 10/31/19

Dark Thoughts

To understand dark thoughts we need to wipe away our existing notions of the words and approach things with a fresh set of eyes. Let’s examine things with an open, inquisitive mind.

Mental experiences

Obsessions exist in the realm of mental experiences. They are subjective. I can’t tell what’s going on in your head - but you can. Similarly, you can’t tell what is going on in my head. But we can agree that there are types of mental experiences. Here’s something I’d like for you to play with: the user interface of the mind is built to simulate social interaction between two people. For example, I can talk to myself. Talking to myself involves speaking, internally to myself. My self or mind can talk back to me. It can communicate with me verbally (eg “Remember to mail that letter”) .

In addition to verbal interactions, my mind can communicate to me in other ways - with emotions. So what exactly is an emotion? We can slide down a slippery slope easily on this one. I will take a stab at a generic description for now (for more on this, Paul Ekman and Richard Davidson have a thoughtful book called The Nature of Emotions). Let’s say emotions are subjective, perceptual “states” of being that feel pleasant or unpleasant, with varying intensity. They can be brief or longer lasting, they have a “motivational” quality - in that they propel us to certain actions. They also have a social, communicative quality in that I might feel the urge to share or “let out” something or often others can guess or relate to what I am feeling.

Emotions are like colors - there are some primary ones and then there are an incredible assortment of blends. In OCD, the dominant emotions are anxiety, fear, panic, shame and disgust. Back when I was in academia, I had a conversation with a friend of mine who was trying to do a research study on emotions and the kinds of thinking that arises with specific emotions. One day I ran into him in our office hallway and he looked really frustrated. I asked him what was going on. He told me he was having trouble with his study because it was extremely difficult to devise aa procedure that cleanly and consistently produced a single emotion. “There’s always other stuff going on!” He told me that people might be anxious but also irritated; or a little sad. My take home message from this is that emotional experience can be simple at times, but a considerable amount of times it is complex. Sorry to make things even more complicated, but in OCD, people can feel considerable anxiety, panic, or fear about experiencing anxiety, panic, or fear. These “meta” emotions are emotions about an emotion. “I’m angry that I feel scared” or “I’m ashamed that I feel so panicked”. or “I’m nervous that I might get scared”. So besides verbal interchanges, our mind can communicate with us with emotions, and with emotions about emotions.

Our mind also communicates with us via intuitions and urges. An intuition can be thought of as emotion-laden sense of “knowing”. Here are some examples of types of intuitions: “I just know that this is the right thing for me to do”; “I have a feeling that something bad is going to happen”. Closely aligned with intuitions is another type of mental experience: urges. When partnered with emotions, urges are strong propellers of action. “I need to get out of here”. An urge is almost like an unpleasant feeling about being inactive coupled with a “promise” that some goodness will arrive if I engage in a specific action. Let’s look at thirst. I once was hiking on a trial in the Grand Canyon and ran out of water. My mouth was parched and I felt this uneasy dry mouth feeling - I’d also get images of being at the Canyon lodge cafeteria drinking a tall tumbler of water filled with ice. I could visualize it and it looked so gorgeous and I could feel that cold rush that would happen as I tipped the glass and felt the water gloriously run through my body. Do you know that feeling? So urges have this dual action of uneasiness with the present combined with a sense of fulfillment when the desired action is taken.

So let’s summarize. We talk to ourselves. We talk to our mind and our mind talks back. Our mind is not a unitary virtual person, but instead a variety of characters. Our mind communicates with us conversationally with words, with images, with emotions, with urges, with intuitions. See where I’m going with this? So far so good. But we haven’t addressed obsessions, compulsions, and all that good stuff. But before I do, first let’s characterize a few more players.

The negative propaganda machine

I’d like to propose to you that our minds have certain pumps; these pumps pour specific kinds of thoughts into our consciousness. I had the good fortune to be listening to an interview with Bill Nighy, a British actor who has been in a number of movies that I really like. This was back when I used to listen to radio. Remember the radio? Anyway, the conversation turned to depression and he described an inner voice he struggled with - he called it the negative propaganda machine. He described how it would fill his mind with dark, critical, horrible statements about himself; about his work, relationships and about his personhood. I could relate to this. What is this thing? This soulless machine pumping negative junk into my mind space.

Negative Automatic Thoughts

The negative propaganda machine was a central piece to the pioneers of cognitive-behavior therapy. In the formulation of what would eventually become cognitive therapy, Aaron Beck wrote that a depressed patient he worked with “consistently embraced a negative construction of himself and his life experiences”. These negative constructions included negative judgments of the world, the future and oneself. Today, psychologists

who specialize in CBT are interested in thoughts or thinking that have specific attributes. Early on in the development of CBT, researchers were interested in negative, automatic thoughts (NATs): automatic spontaneous thoughts about the self, self-efficacy and the future (“you are a loser”; “you will never succeed”, “you are going to become destitute and alone”). These thoughts “pop into” awareness, sometimes out of the blue, but often are triggered by situation you are in or what you are thinking about or doing. They seem to revolve around themes of loss, failure and danger. NATs are common, especially in depressive and anxiety disorders. NATs show up verbally; to the person experiencing NATs, the NATs seem believable and the person may even agree with them at times (“I really am hopeless”).

So far, we’ve speculated that my mind and I communicate with each other. My mind is complex and communicates in a variety of ways (via thoughts, images, urges, intuitions) and there are “pumps” that infuse my consciousness with specific kinds of ideas, images, urges or intuitions. One such pump is the negative propaganda machine that pumps NATs - negative thoughts about myself, my world and my future into my awareness. But in this story, there is another pump and it is even weirder and freakier than the negative propaganda machine.

The slime machine

Slime is popular these days. Kids like to make homemade versions of it. But I think it is gross. I don’t like it and if I get some on my hands, I will try to get it off as quickly as possible. Merriam-Webster offers up two curious definitions of slime- a viscous, glutinous or gelatinous substance and a morally repulsive or odious person. One definition is a physical phenomena and the other is a mental or social phenomena. And just like the Nickelodeon channel’s tendency to drop slime on people’s heads, we have a slime pump that drops slimy thoughts into our consciousness.

Disturbing, unwanted thoughts. Where do they come from? What do they want? What are they?

Thoughts like: “What if I left the door unlocked and an intruder is inside?” “What if I drove off the road right now?” “What if I had an impulse and caused a scene?”

73 - 60 - 45. These are the percentages of people who report that they have had the above disturbing thoughts frequently (if you have access to it, the research study was reported in a paper by Purdon and Clark in 1993 in Behavior Research & Therapy).

But wait there’s more. In their study they found that 21% of a random sample of young adults reported being disturbed by thoughts like “When I see a sharp knife, I have the thought of slitting my wrist or throat”. 48% reported having unwanted thoughts about running over pedestrians or animals while driving; 19% had frequent unwanted thoughts about exposing themselves in public and 55% reported unwanted sexual thoughts about a boss, teacher or other authority figure. Whoa! What’s going on here?

A more recent series of papers reported findings from an international multi-site study on bad slimy thoughts. Psychologists and psychiatrists call these types of thoughts intrusions. It looks like the slime machine pumps in intrusions in almost everyone. 96% of people in Turkey, 97% of people in Hong Kong and 100% of people in Iran who participated reported having these kinds of intrusive, disturbing thoughts in the past three months. Sadly, North Americans, South Americans and Europeans too had percentages ranging from 84% to 100%. Remember these participants were drawn from the general population, not a mentally unwell subgroup. Radomsky and a large group of coauthors summarized their findings in the Journal of Obsessive-Compulsive and Related Disorders in 2014.

Just like the propaganda machine that pumped in scary, depressing, hopelessness generating thoughts about ourselves, our world and our future, it seems like the slime machine pumps in weird, disturbing and shocking thoughts. Although nearly everyone seems to have these thoughts there are occasional. Thankfully the slime machine doesn’t repeatedly dump their minds with sludgy, slimy thoughts.

But what if it did?

Obsessions

Some people get deluged with disturbing thoughts that they struggle mightily to get rid of. We can imagine that their slime machine is big and nasty. Let’s call these kinds of thoughts obsessions.

In contrast to intrusions, that are experienced by virtually everyone, obsessions are different. Obsessions are more frequent, associated with stronger negative emotions, are considered more meaningful, and come with a much stronger urge to resist.

An unresolved puzzle is whether obsessions are intrusions that morphed into obsessions, or whether they are two separate things that have some similarities. We can explore that down the road, but for now, suffice it to say that our minds communicate with us via thoughts, images and impulses. Also, our mind has a few mental machines that squirt thoughts into our awareness. Some are like NATs, some are intrusions, and for some people, there is an obsession machine.

David A. Clark (in Cognitive Behavior Therapy for OCD, 2004) writes that obsessions have five attributes. They are: 1) intrusive; that is to say, the thought, image or impulse enters awareness “against one’s will”; 2) unacceptable - they are distressing in varying intensity to the person having the obsession; 3) accompanied by an urge to resist, the person feels a strong urge to resist, suppress, dismiss the obsession from conscious awareness; 4) uncontrollable , a person senses that their ability to control or suppress the obsession is i too brief or ineffective; 5) ego-dystonic meaning the obsession can (but not always) involve ideas that might be threatening to one’s sense of self or violate one’s sense of values or morality.

There is one last quality to obsessions that make them stand out: the person experiencing them can have trouble distinguishing the obsessional mental experience from tangible reality. A thought feels like reality. If I have a thought that I might be a child molester, I may actually feel like I am a child molester. If I see an image of a spider, I actually feel like I am seeing an actual spider. This blurring of the lines between external reality and subjective experience is extremely disturbing to the experiencer. Some people have described to me that at times, when anxious, they feel like they have a split brain - one part that “sees” that what is going on and realizes it is irrational, and another part that “feels” the obsession is real. The path to getting through and managing OCD can be difficult. But starting with a willingness to learn and understand what obsessions are and how our minds tend to work can help in making the route clearer.

Sarosh Motivala, PhD 10/24/19 Sarosh Motivala, PhD 10/24/19

The Focusing Response

You’ve heard of fight or flight of course. The two most thought about responses to a stressor or threat. Lesser known is the freezing response. You can see this one in animals. Freezing is a fairly automated response to an immanent predatory threat. Fighting, flighting, freezing all have their uses, but none of them are well suited to chronic stress. All of them are good for short bursts. The talent and skill needed for sprinting are different than those needed for a marathon. And make no mistake people, we are all in a marathon.

So is there another way to handle stress? Especially chronic stress? Yes. the focusing response.

Now there is a surface meaning for the word focus and it sort of gets at what I am talking about, but then there is a deeper, more mysterious meaning for the word that lies at the center of what I am talking about.

A quick search in the Merriam-Webster Dictionary and we find that focus as a noun has a few different meanings, including - 1) the center of attention; 2) directed attention; 3) “a state or condition permitting clear perception or understanding”. This is focus as a thing; but now, I’m thinking of focus as a response - an action, so let’s examine it’s definition as a verb. To focus means 1) to concentrate attention or effort; 2) to bring cause to be concentrated. On the surface, pretty straight forward. But now I’m going to make things weird. Before we leave Merriam-Webster, our stately dictionary adds a scientific definition - the point where geometric lines either converge or diverge and intersect, giving rise to an image (in a mirror or lens). Does this seem confusing? Let’s say it’s an apt way of describing the action of “bringing the lines of thought together” and also the location of “where things come together”. I like that. The Oxford Dictionary spells it out a little differently: “to adapt…so that things can be seen clearly”.

So far, some pretty good ways of defining focus. But here is where it gets even more interesting. The Oxford Dictionary goes on to say that the beginnings of the word focus are in the 17th century when it was used in mathematics and science, but its origin predates this, back to the Roman Empire, when the Latin word “focus” meant domestic hearth. Now, this is to me the deeper mysterious meaning of the word focus - domestic (or home) hearth, meaning the center of the home that provides warmth, light and sustenance. As Jim Morrison swaggered and sang, “Let me sleep all night in your soul kitchen, warm my mind near your gentle stove”, to me, focusing has a centering, rejuvenating feel to it. Jim was singing about going to the hearth after what was probably a long and crazy night out. To focus is to go to the hearth; to go to the center. But where is that exactly? Is it even a “place”? I think it is.

Centering is a nice way to think about focusing. In Peru, the ancient capital of the Incan empire was Cuzco. What a mysterious name! What could it mean? Turns out it means navel of the world. In old Incan culture, the navel was the center of a person’s being, the place where a person is connected with the universe through a spiritual umbilical cord. So the center of the soul of the Incan empire simply had to be named Cuzco. Their capital was the center of the world (to them) and was where they connected with the universe. Getting focused means “going to your Cuzco”. In humans, wanna know where our center of gravity is? Can you guess? Yup - the navel. Your center of gravity is where your hearth is; it’s your soul kitchen as Jim Morrison would say. And lastly, Hindu traditions conceptualize our bodies have energy centers called chakras. My grandfather used to tell me that the third chakra was the one that had fire and the warm burn of a home hearth as its symbol. Can you guess where that chakra is located in the body? It is located just above the....drum roll please...navel! So the statement “get centered” literally means “go to the navel”. Is it any coincidence then that belly breathing, so vitally important in yoga and meditation, is a way to get centered and to get focused?

Now let’s operationalize these varied definitions into something practical. I’m thinking that the focusing response first involves centering, or going to the navel, or going to the hearth. Whatever phrase you like better.

You go there not with your feet, but with your attention. So you take your attention to your belly. Four to five breaths should do it, but if you want to warm your mind by the gentle stove for while longer like Jim did, have at it.

Ok, after centering, the next step of focusing is observing/noticing. There are two basic things to observe. The outside or the inside. It’s hard to notice both at the same time. The outside could be visuals like people, birds, trees, or scents, odors, or sounds, or touches - the sun on your skin, the feel of air rushing into your nose, the feel of an ice cube on your finger tips. Then there’s the insides. Maybe it’s a radiating warm feeling in your belly, a tightness in your shoulders. Insides also include your mindspace. Maybe you notice a certain rush of thoughts, with a certain kind of intensity or flow to them.

Lastly, you practice welcoming/accepting. This is a verbal statement you make. I’ve heard people advocate for a welcoming statement like “I welcome this feeling of tightness” or “I welcome this feeling of fear”. This is not really my speed. I don’t have anything against this style, I just don’t talk to myself that way. I like a different welcoming form of self-talk - something like “this is good - this is ok. It’s fine to feel fear or tight. let’s go - you got this”. That last bit of “you got this” is like adding a little bit of seasoning to the acceptance pot - the specific seasoning being something called self-efficacy, a statement that you can handle this.

So to review, start with centering and going to the navel via your breath, then you do a bit of observing of your body state and your surroundings and then you close it out with a welcoming statement. That’s my way of focusing and developing that fourth fear response.

Sarosh Motivala, PhD 10/24/19 Sarosh Motivala, PhD 10/24/19

Here we go round again

“And now we’re back where we started

Here we go round again

Day after day I get up and I say

I better do it again”

Ray Davies/The Kinks

Compulsions refer to a set of behaviors, within the context of obsessive-compulsive disorder. So, this means I am leaving out a lot of other behaviors that some people call compulsive, involving substance use, shopping, or pornography. I am leaving this out so we can get some clarity and specificity about to talk about.

According to the diagnostic manual, the DSM-5, compulsions are:

Repetitive behaviors that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. The behaviors are aimed at preventing or reducing emotional distress, or preventing some dreaded situation. The behaviors are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. Whoa, that is a lot of dense content crammed into two sentences. Let’s unpack it all piece by piece.

The definition starts with Repetitive behaviors… what exactly does this mean though? I like applying Low’s definition of stereotypy to flesh out what we mean by repetitive behaviors: “a behavior or sequence of behaviors being repeated in excess of their normal functional requirements.”

Ok, now that we have a grip on repetition, this comes next - that the individual feels driven to perform…so this part is not about the behavior itself, but describes an unpleasant feeling state that precedes the behavior. We can call this an urge that feels like being pulled to action. This urge can be strong, sometimes incredibly strong and difficult to resist.

in response to an obsession or according to rules that must be applied rigidly. so this places the behavior in the context what we can call the “OCD cycle” (more on this later). The compulsive act comes after an obsession thought. Thus obsession and compulsion are joined together. But the definition adds an additional phrase reminding us that alternatively a compulsion can occur when I rigidly apply a rule or a set of rules regardless of context. (“all doorknobs are dirty”).

Quick recap. Compulsions are repetitive behaviors that go above and beyond what the situation requires. Before the compulsions there is an urge to do the compulsion, and before the urge,there is an obsession. Thus obsession, urge and compulsion form a cycle. Now onto the next part of the definition. The behaviors are aimed at preventing or reducing emotional distress,…now we get to the purposes of the behavior. This first one is emotion focused. The behaviors are aimed at reducing anxiety, disgust, shame, horror when we are triggered. But in addition, I might also start behaving compulsively to prevent even getting triggered.

Besides preventing or reducing emotional distress, compulsions are also aimed at “…preventing some dreaded situation.” There are an infinite variety of dreaded situations including death, illness, burglaries, fires, theft, injury, becoming homeless, getting arrested, or even offending someone. Do I need to go on? You get the idea. Let’s add one more type of dreaded situation: the possibility of being a deviant, pariah, morally corrupted or sick person.

I wish the DSM-5 had added a little piece saying “compulsive behaviors can also be aimed at preventing or getting rid of the obsession thought”. Think of your mind as the space where your self or your consciousness lives. We don’t want obsessions that are gross, sick, perverse, scary, or just plain awful to invade and then become “squatters” in our mind space. So we employ actions to try and get I’d of these thoughts. Thought replacement, praying, chanting can become compulsive strategies to try to remove obsessions from our mind.

The compulsive checklist

Here then is our checklist to see if a behavior is compulsive:

● Is it very repetitive?

● Does the person feel really driven to perform it?

● Is the behavior part of the OCD cycle, in which it is in response to an obsession? Or part of a set of rules that must be followed rigidly?

● Is it aimed at reducing distress, a dreaded outcome or removing a bad thought from my mind?

The Compulsive Big Six

The central aim of a compulsion is to do one or more of the following: 1) reduce feeling bad, 2) make a dreaded outcome less likely; 3) remove a bad thought from my mind. OCD specialists have described compulsions in many different ways and broken them down into many different categories. Here’s my stab at it.

Rituals

Cleaning

Checking

Reassurance providing

Mental neutralizing

Avoiding

Rituals are formula-ized actions. Do the action in the same way each time. They are done in a standardized manner, with a set order, with fixed repetitions and mannerisms. Deviations are not allowed and the whole thing has to be repeated if even small alterations are made. Praying, chanting, lifting weights, maybe even baking can be ritualized but NOT compulsive. What makes a ritualized behavior compulsive? Well, let’s go back to the compulsive checklist above. And just a final note, I can be repetitive but not ritualized. I can do something over and over, like something observable like washing, or something more internal, like worrying. However, it may or may not be done in a ritualized manner with a fixed order, number of repeats, a fixed number of things that I think about, a fixed way I think about it etc. So being ritualized is different from being repetitive.

Cleaning compulsions range from showering, hand washing, tooth brushing, using sanitizer to doing laundry. Cleaning compulsions can also involve excessive cleaning of rooms or items around the house (or getting someone else to clean around the house). They are very often ritualized, but not always. Even if the cleaning is not ritualized, there’s not a lot of flexibility and it’s almost always rigid.

Checking How do I know that I know something? Knowing is a sense. 2 + 2? I know the answer and I know that I know the answer. 47231 + 3428 = ? I don’t know the answer but I know that can know it (by doing the math) fairly easily. Imagine the opposite. I recognize someone; I know that I know them but I just can’t place them. I don’t know their name or who they are. Then maybe in a few minutes it will come to me. That’s Bob from my old macrame class. What if this sense of knowing was malfunctioning in a few specific areas? Is the door locked? Did I do something wrong a while ago and I can’t remember for sure? Checking (really rechecking and rechecking) can take shape is such a variety of ways - staring, retracing my steps, checking the house alarm, checking the faucets.

Reassurance is a checking-adjacent behavior. Like checking, reassurance seeking is a confirmation seeking action, but it has a social piece to it, in that it involves lots of repetitive asking (“Did I wash my hands properly?”, “Did I just run someone over? Did I just say something offensive to someone?” Sometimes an answer from another person isn’t even needed, just the action of asking for reassurance fulfills the requirements of the compulsive urge. In contrast to reassurance questions, reassurance can also be an answer I repetitively tell myself basically saying “I’m ok, it’s ok, everything is going to be ok” “I didn’t do that bad thing”, “I’m not a bad person”.

Mental Neutralizing is aimed at mental “undoing”. Freeston and Ladouceur (1997) describe a neutralizer as an act aimed at removing, preventing or weakening the obsession or the anxiety or distress that accompany it. As an example, I can imagine a good thought after having a bad one, the idea is to undo the bad thought. Chanting, praying, repeating a particular phrase, taking an obsession word and repurposing it somehow can be a neutralizer as well.

Avoidance. The lure of avoiding triggering situations, people, images, and thoughts can be extremely strong. And avoiding is not necessarily bad. In fact it can be very helpful. But when avoiding causes a progressive narrowing or constricting of my life experiences, when I repeatedly turn away from my triggers, it can make me even more sensitive to anxiety. So in fact in my attempt to get away from anxiety, I become more anxiety sensitive. This means I feel it more intensely and in response to an ever expanding list of triggers.

Perhaps all of these actions I’ve discussed can be called “actions to escape from feeling bad”. The frequent use of these avoidant strategies produces more and more anxiety. Why would we do something that causes the thing we are trying to get away from? The answer is not so easy, but in OCD, the answer lies at least partially in an understanding of habitual behaviors.

Our minds are built to automate. It is a deep, deep aspect of how our minds handle engaging with the world.

Think about driving. Think about a golf swing, or a tennis serve, or even beating an egg. Think about the 15-20 times you did those things. Remember how awkward and unnatural they were?

Think about how you drive now (if you do). You know how to turn the wheel to turn the car, how much pressure your foot needs to slow the car down. All so routine and natural now. I bet you can parallel park like a boss now. But not at first right? So driving has become habitualized. What does that mean? It means that you have integrated a complex chain of fine and gross motor movements, blended seamlessly with “hand-eye” coordination. If you play a lot of golf, even if you don’t like your golf swing right now, compare it to someone just starting out. For better or worse, their swing is not habitualized yet.

A complex chain of behaviors that are habitualized are semi-automated. This means that I don’t have to devote much thought to them. Sometimes your coach or piano teacher might even encourage you to “not think so much” because it might be getting in the way.

Sometimes when you do these habitualized behaviors you might get a little “ah” feeling - like when your forehand in tennis hits the ball right in your racket’s sweet spot; or when you hit a smooth consistent stride while running. It feels right - and the reward is a feeling that it feels right. We don’t get that feeling all the time, but we know it and remember it and hope for it.

So far so good. This is the sunny side of the story. But, as you know there are problematic habits. My old guitar teachers used to tell me variations of “practicing bad form teaches bad form” and “slow down! Playing fast and making mistakes teaches your fingers to keep making those mistakes.”

An interesting thing about habits is that they seem to be independent of distant, “objective” rewards and punishments. I fall victim to doing the habit despite my knowing it isn’t “good for me”. Learning theorists speculate this is because habit behaviors are not tightly tied to our sense of goal driven action, but are more stimuli triggered.

So, I hope this overview gives you a sense of how complicated and difficult it is to have OCD or chronic anxiety. I hope this write up conveys how hard it is to work on getting better. It’s not easy, but it can be done, step by step.