OCD Beyond the Stereotypes: Understanding the Cycle and How ERP Can Help

What do you think of when you hear Obsessive-Compulsive Disorder or OCD? Perhaps Monica from the popular sitcom Friends comes to mind. Her rigidity, cleanliness, and need for control is often the butt of a joke. The show portrays her implied OCD diagnosis as a personality quirk or an endearing feature of her identity. Monica enjoys this aspect of herself and gleans satisfaction from her need for perfection. She believes her cleaning expectations and abilities are superior as she exclaims in one episode, “It’s not just health-department clean, it’s Monica clean!”. Unfortunately, this is the picture that many people see in their heads when they think of OCD and this is a gross misrepresentation of the disorder. OCD is not quirky, enjoyable, or fun. It is a serious, life-altering disorder that causes extreme distress in those living with it. It is characterized by ego-dystonic intrusive thoughts, or thoughts that are inconsistent with someone’s true values or beliefs. OCD is historically and globally ranked amongst the top debilitating conditions of any kind. 

So, what does a more accurate picture of OCD look like?

We all have intrusive thoughts from time to time. You know the ones…you’re driving down the road with a loved one in your passenger seat and out of nowhere you have the thought, “What if I swerved into oncoming traffic right now?” You say to yourself, “whoa, that was a bizarre thought, I would never do that”, and then carry on driving to your destination. You don’t think twice about it. The thought enters your mind and exits just as quickly. You keep living life normally as if you never had the thought at all. 

Now, imagine the same scenario. You’re driving down the road with a loved one in the passenger seat next to you. You have the same intrusive thought, “What if I swerved into oncoming traffic right now?” Again, you say to yourself, “Whoa, that was a really weird thought, I wouldn’t do that!”, but it doesn’t stop there. You panic and the questioning begins. “Why did I have that thought? What does it mean? Do I actually want to swerve into oncoming traffic? Would I swerve into oncoming traffic? That would be so horrible and it would have a devastating outcome! Why would I have such a horrible thought? Maybe the fact that I can have such a horrible thought means that I actually want to swerve into oncoming traffic. What does this say about me as a person? Am I actually a sociopath?” 

The questioning escalates. “Should I pull over and stop the car in case I somehow lose control? No, that’s crazy! We are almost to our destination and then my loved one will be getting out of the car. I’ll feel better then because I won’t be worried about causing her any harm.” You power through, arrive at the destination and your loved one gets out of the car. “Whew!”, you think, “We made it safely and I don’t feel scared anymore.” You get back on the road, you see the other cars coming towards you, the questioning and anxiety return. “What if my brain glitches and I jerk my wheel? I would hurt so many people. Am I actually a danger to others without realizing it? How can I be certain that I won’t swerve into oncoming traffic? I don’t feel certain. I need to feel certain. Safe people probably don’t question these sorts of things. Maybe I should turn myself in to the police. Or maybe I should stop driving on busy roads. I’m certainly not going to have any passengers in my car from now on. Maybe the only way I can be certain that I won’t harm anyone is to stop driving all together.”

You arrive at home, you feel your anxiety drop, the problem is solved. The intrusive thought dissipates. You carry on with your evening. The next day, you begin to leave your house. You get in your car, start it, put it in drive, and the intrusive thought along with the questioning and panic flood in. You see images of yourself swerving into oncoming traffic and experiencing the aftermath. You try to shake the thought out of your head but it’s stuck. Even though a part of you recognizes the irrational nature of your fear, you can’t overcome it. You feel paralyzed. You are overwhelmed. You decide the risk is too great. You put your car back in park, shut it off, and go back inside. “I can’t hurt anyone with my car if I don’t drive”, you say to yourself. Once again, the anxiety drops and the intrusive thought goes along with it. 

Days go by and everytime you try to get in your car to go somewhere, the intrusive thoughts, the questioning, and the panic return. You know that if you avoid driving you will be spared the mental spiral and eliminate the potential risk of hurting someone, so that’s what you do. You avoid driving all together. This goes on for weeks, months, and then years. You have to rely on other people for rides or walk to places that are close by. You’ve lost the convenience of reliable transportation. You’ve lost your independence. You’ve lost a part of yourself.

This scenario illustrates a common example of Harm OCD, just one of the infinite subtypes of OCD. A person living with this Harm OCD experiences extreme fears that they might accidentally or unwillingly cause harm to another person. In an effort to extinguish their fears, they engage in compulsions like mental rumination, reassurance seeking, or avoidance. The compulsions decrease their anxiety, but with OCD, the relief doesn’t last. The moment the thought or trigger returns, so does the anxiety. The compulsion is repeated and sends a message to their brain that says, “That thought was dangerous. It’s a good thing I did that compulsion or something bad may have happened.” A cycle is initiated. Every time a trigger or intrusive thought is presented the response is the same. Anxiety spikes, compulsions are carried out, relief is temporarily achieved, the pattern is reinforced, and the cycle continues. Someone with OCD can spend hours, days, weeks, or longer stuck in this cycle without being able to break it and without gaining lasting relief from the anxiety which can become debilitating. That’s where ERP comes in.

ERP or Exposure and Response Prevention therapy is the gold-standard evidence-based treatment for OCD. ERP, a type of cognitive behavioral therapy, works to break the cycle of OCD by targeting the response (compulsions or avoidance) someone has to intrusive thoughts, triggers, and obsessions. The content of the intrusive thoughts is not analyzed in the way thoughts may be addressed in a more traditional talk therapy. In fact, trying to treat OCD this way can perpetuate the cycle and actually cause harm. ERP takes the stance that the thoughts themselves don’t matter. It’s what a person does in response to a thought that either creates, perpetuates, or breaks the cycle. 

ERP works to break the cycle by deliberately and gradually exposing the person with OCD to their fears and teaching them to sit with the discomfort and uncertainty without engaging in compulsions or avoidance. By doing this, the person with OCD learns that when triggers are presented, anxiety will spike and naturally fall on its own without needing to engage in compulsions or avoidance. They also learn that the feared consequence doesn’t actually happen (disconfirmation) and/or they can tolerate the uncertainty related to the feared consequence. 

To apply this explanation of ERP to the Harm OCD example above, a therapist would work with their client to explore triggers related to their intrusive thoughts, obsessions, and feared consequences. These triggers might include driving on a busy road, driving with a passenger in a car, or driving, period. The therapist would then take these triggers and break them down into exposures to create an exposure hierarchy. Because having the client get in a car and drive immediately would likely be too intense to begin with, the task would be broken down over several weeks. The first exposure they do might be just sitting in the car with the keys out of the ignition. A second exposure may be starting the car. A third might be putting the car in drive momentarily. The exposures would escalate until the client reaches the top of their hierarchy: driving the car on the busy road. As the client completes each of these exposures and sits with the anxiety that arises they learn that they don’t have to engage in the rituals they once did for the anxiety to fall. They learn that they can handle the discomfort and the uncertainty. They learn that they can be free of OCD’s trap. They regain their confidence and independence. They get their lives back.  

Contrary to what the writers of Friends may have believed, OCD is not a joke. It is serious. It can steal so much from a person including their time, energy, and peace. It can lead to depression and/or suicidal ideation. It can feel like torture but it doesn’t have to. There is a way out through ERP.

If you or someone you know is struggling with OCD, help is available. You can learn more about OCD and ERP at the International OCD Foundation or by reaching out to me, ERP therapist Rose Heater at Thomas Integrative Psychotherapy.

Law, C., & Boisseau, C. L. (2019). Exposure and Response Prevention in the Treatment of Obsessive-Compulsive Disorder: Current Perspectives. Psychology research and behavior management, 12, 1167–1174. https://doi.org/10.2147/PRBM.S211117

IOCDF. International OCD Foundation. (2006). https://iocdf.org/

What is ERP Therapy & How does it help OCD?. Cleveland Clinic. https://my.clevelandclinic.org/health/treatments/erp-therapy