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Plagued by a fear of spreading deadly germs, Jennifer washes her hands for exactly five minutes every hour, even when she hasn’t left the house all day. At work, she frequently excuses herself from calls or meetings to maintain her ritual.

José feels certain that if he doesn’t organize his closet in a particular order, he’ll wear mismatched clothes and be mocked by his colleagues. If a stray sock or tie disrupts his ordering system, he panics and can’t leave home until the system has been restored.

Nothing is more important to Lisa than her baby’s safety. But no matter how carefully she puts him down for naps, Lisa continually imagines her son falling out of his crib. Whenever these images cross her mind, she checks on him. As a result, she can’t concentrate on other tasks throughout the day and often wakes up in a panic at night.

Jennifer, José, and Lisa all share characteristics of obsessive-compulsive disorder (OCD).

It’s a relatively common condition: As many as 2.3 percent of individuals will meet the criteria at some point in their lives. Most of us worry at least occasionally about what might go wrong if we don’t plan ahead or follow safety precautions, and to an extent this vigilance is essential to our survival (imagine what would happen if we didn’t make sure the oven was turned off after baking). For those diagnosed with OCD, however, the worries and precautionary behaviors are so time-consuming and difficult to control they interfere with daily life.

How OCD Works

OCD is grounded in a fixation on what might happen. Defined as obsessions, these what ifs often involve fears of harm befalling oneself or someone else, such as getting sick or getting into a car accident. But they can also include fears about one’s own capacity for inflicting harm: What if my “dark” thoughts mean deep down I am an evil person? What if I lose it and strangle my child?

The what ifs become a pervasive, distressing drumbeat. And while the probability that they may come true often ranges from somewhat possible to highly improbable, it’s virtually impossible to know for certain, let alone feel certain, that they won’t.

It’s that feeling of uncertainty — the anxiety — that sets off the second part of the OCD equation: compulsions.

These behaviors temporarily alleviate the anxiety associated with a particular what if. Compulsive behaviors can range widely, from those directly related to the individual’s fear, such as repeatedly checking that the doors are locked, to those that may seem (to an outside observer, at least) illogical or even superstitious, such as whispering a prayer anytime a “bad thought” crosses one’s mind or arranging everything in sets of three.

No matter what form they take, to qualify as a compulsion the behaviors must be unrealistic or excessive and difficult to stop, even if maintaining them gets in the way of living one’s life.

So why do they start in the first place?

Research suggests that OCD is both inherited and learned: A biological predisposition sets the stage; experience sets it into motion. Some people can identify a clear origin for their particular what if, such as enduring a life-threatening trauma. Others who suffer from OCD may not be able to trace the root cause of their obsession.

Arguably more important than why they form, how OCD patterns solidify tells us much about why they can become so debilitating.

Though they don’t actually prevent the what if from coming true, compulsive behaviors alleviate — at least temporarily — the fear that it might. Just as behaviors that bring about positive feelings can be addictive, so can those that take away distressing feelings. Known as negative reinforcement, the cycle is powerfully self-fulfilling: The more an individual trains his or her brain to believe he or she can only ease a particular fear through a compulsive behavior, the harder it is to stop that behavior — irrational as it may seem to others.

OCD Treatment options

OCD can be exhausting, embarrassing, and in its most severe manifestations incredibly debilitating, leading some toward prolonged isolation. Fortunately, the disorder can be effectively treated.

By mitigating the physiological response to triggering situations, certain medications make it easier for individuals to tolerate feelings of anxiety and resist the urge to ritualize. Yet medication tends to work best as a complement rather than a substitute for therapy, specifically a technique called Exposure and Response Prevention Therapy (ERPT).

Supported by a raft of clinical studies, ERPT is considered the first-line approach to treatment for OCD. It involves purposely engaging with a triggering situation, then resisting the urge to carry out the anxiety-relieving compulsion. Instead, the individual must tolerate the anxiety until it naturally begins to dissipate, which may take several minutes or several hours.

The individual repeats this procedure at regular intervals until the triggering situation no longer elicits an anxiety response, a process known as habituation. At this point, the individual has learned that he or she can tolerate the what if without resorting to compulsive behavior.

Depending on a person’s triggers, he or she may then replicate the procedure with more distressing situations. For example, Jennifer might first use ERPT to resist compulsively washing her hands at home, then at work, then eventually in other public settings.

Overcoming OCD also entails learning to accept that no matter what one does or doesn’t do, it’s impossible to know for certain that a feared outcome won’t come true. That means Jennifer learns to accept that no matter how many times she washes her hands, she can never guarantee that she won’t inadvertently spread germs. No matter how perfectly ordered his closet, José may one day accidentally sport mismatched socks. No matter how many times Lisa checks on her son, he may someday have an accident.

Learning to live with what ifs is not easy. But uncertainty is a part of life, and accepting it allows for the freedom to simply live.

OCD and COVID 19

Not surprisingly, the COVID 19 pandemic has presented significant challenges for those dealing with OCD-related contamination, as well as individuals who struggle with OCD involving perfectionism or fears of harming others.

Increased risk of contracting or spreading a dangerous disease may seem to justify excessive cleaning, checking or performing other protective rituals, and to be sure, greater vigilance has been necessary to slow the spread of COVID. But caution can quickly give way to debilitating compulsion among OCD sufferers.

The International OCD Foundation offers a list of suggestions aimed at helping suffers remain safe without exacerbating their symptoms. The organization encourages individuals to follow but not add to precautions recommended by the CDC, and to limit time spent gathering information about COVID safety. Their website also includes resources for self-care and a directory of therapists who specialize in treating OCD.

Alexandra Smith, MA, LPCC

Alexandra Smith, MA, LPCC is a licensed professional clinical counselor in Minneapolis.

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