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Obsessive Compulsive Disorder / ep49 show notes

Updated: Mar 27, 2020

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**Disclaimer: This information is NOT meant to diagnose. If you feel like you may be experiencing symptoms of obsessive compulsive disorder, consult with a mental health or medical professional. I am speaking in generalities. Your specific situation, diagnosis, treatment and medication are entirely between you and your provider.

**This is how I am conceptualizing and would begin with a client, but every situation is very different in every way.


"Obsessive-Compulsive and Related Disorders (OCRDs)," which also includes body dysmorphic disorder (BDD), trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder, hoarding disorder, substance/medication-induced OCRD, OCRD due to another medical condition, and other specified OCRDs -

  • These probably have similarities in polyvagal terms


Obsessions are different than rumination in anxiety -

Rumination is: stuck thought due to a stuck state. Stuck flight energy with no direction leads to anxiety which leads to repetitive thinking, searching for a solution but there is none. Because story follows state.

  • Perceived danger trigger or stuck anxious state →

  • Neuroception of danger leads ANS to shift into sympathetic flight energy. →

  • Thoughts change to match. (“Story follows state”) →

  • But there’s no actual danger, so the state gets stuck. Which means the thoughts get stuck as well.

Different than an actual danger trigger, then shifting, then using the energy to get to safety

Rumination is also grounded in real world events. It’s anxiety placed onto events from the real world, like with the recent coronavirus pandemic.

Compare this to an obsessive thought:

  • “I couldn’t do anything without my rituals. They invaded every aspect of my life. Counting really bogged me down. I would wash my hair three times because three was a good luck number for me. It took me longer to read because I’d have to count the lines in a paragraph. When I set my alarm at night, I had to set it to a time that wouldn’t add up to a ‘bad’ number.”

  • “Getting dressed in the morning was tough because I had to follow my routine or I would become very anxious and start getting dressed all over again.” I always worried that if I didn’t follow my routine, my parents were going to die. These thoughts triggered more anxiety and more rituals. Because of the time I spent on rituals, I was unable to do a lot of things that were important to me. I couldn’t seem to overcome them until I got treatment.”

An obsessive thought is disruptive of daily life, chronic, attached to a solution

CRITERIA A: Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):

1. Recurrent and persistent thoughts, urges, or impulses that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.

"Persistent thoughts" - "story follows state" (Deb Dana)

  • If the state doesn’t change, the story stays

  • The state is persistent, so the story is persistent

  • But to a much higher degree than a ruminating thought

  • Intense thoughts from intense stuck energy

Persistent urges/impulses

  • this seems like it should be under Compulsions since there is a somatic element of doing

Extreme sympathetic flight/fight energy, probably freeze

  • Critical thinking is not available when in a severe defensive state

  • All or nothing thinking

Also seems to be an element of shutdown, which would be present in freeze

  • Thoughts are from the outside, perhaps a disconnection from the self when immobilized with sympathetic energy

2.The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).

Judgment and evaluation, rather than being with the self in the present moment

  • Not easy in this situation and I generally don’t recommend crisis management as the only tx option

Attempt to ignore, neutralize or suppress

  • That’s part of the problem!

  • Our general somatic experiences need to be felt, witnessed, noticed, loved, embraced and allow to go through their process.

  • It’s the opposite of ignoring, neutralizing or suppressing

  • I’m not exactly recommending the person dx’d with OCD to just sit with their feelings, it might be too much, but it’s something that can be worked towards

Flight/panic energy → Do this thing, so something in the future doesn’t happen = future oriented, anxious/panicky

  • We need to be in the present moment both physically and mentally

  • Physical bodies are always in the present moment, we need our emotional and cognitive selves to be in the present moment also

Compulsions are defined by (1) and (2):

1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

  • Rules = control

  • When in flight/panic, we need things to be definite, predictable

  • Rules can be a part of this - predictability, order

Misdirected energy

  • There is an urge to do something to relieve the distress

  • We all do this on some level, like working out, tapping our feet, grinding our teeth

  • But we have to do so mindfully for the energy to actually discharge

The rules create a channel for the energy, but not an exit

  • Like a pipe that feeds right back into itself

There may be a sense of momentary completion, but not of relief or actual energy discharge

2.The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

Preventing or reducing anxiety or distress

  • Versus welcoming the underlying body sensations

  • Anxiety or distress are conscious experiences, but there’s more underneath

  • But we have to be in the moment to access that. With obsessions, it’s about the future, preventing something...

Preventing some dreaded event or situation

  • Again the difference between and anxious rumination and OCD reality-based thoughts

CRITERIA D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).

Yet comorbidity is common: Depression being the most common comorbidity

MDD is 10x more prevalent in OCD clients than general population

  • “depressive symptoms seem to be more strongly associated with obsessive than with compulsive symptoms”

  • Also much higher in Bipolar Disorder clients than general population

  • Suggesting the element of shutdown, which is present in freeze as well

Specify if:

With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.

  • Reminds me of someone who is doing some level of their own work, whatever that looks like

  • Part of the problem of insight based therapy without the somatic pieces attached to it

  • So they get it on some level, but their stories persist, due to a stuck state

With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true.

With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true.


  • Practice being in the moment outside of a crisis

  • Focus on the thing that brings you joy, peace, connection or calm


I’ve just said to my 9 year old daughter, ‘we’re going to listen to Brene today whilst we’re building the desks.’ Her reply, ‘ah why can we not listen to the guy. I like him better.’ Turns out she was talking about you. Shrug emoji, laugh emoji, orange heart emoji -Anonymous

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