Obsessional Thoughts

In my practice, I have seen a number of people who come reporting highly intrusive and distressing thoughts sometimes categorized as "pure O". I want to take some time to address other ‘bad’ thoughts that people may have, yet feel they must keep to themselves due to feelings of shame and guilt. Usually these unwanted thoughts fall into three broader categories that encompass violent, sexual, or blasphemous themes. These may also come in the form of repetitive, recurrent images. As examples, some of these may involve thinking of or visualizing yourself pushing someone onto train tracks, wanting to have sex with a child or family member, using racist slurs, or shouting blasphemous words while in a place of worship. Some postpartum mothers report having distressing thoughts of smothering their baby. These recurrent and intrusive thoughts and images, if left to their own devices, can be appalling to the individual experiencing them and cause quite a bit of emotional turmoil if they are not properly addressed. Many who have these urges might feel they are alone in their suffering and could never mention this to anyone for fear of judgment, embarrassment or disgust at themselves.

If you experience any of these disturbing urges, a good question to ask is, how do I know I would never act on such thoughts? How do you know you are not that murderer or pedophile or racist (or anything else that you deem horrifying)? The truth is, no one can be one hundred percent certain that a situation would NEVER happen. In fact, the notion that there is even the slightest doubt involved is usually enough to torment someone who is suffering from these violent, blasphemous, or sexual thoughts. However, as the saying goes, the best predictor of future behavior is past behavior. If you have never had a previous history of acting on your most feared thought, it is unlikely that you will behave in such a manner in the future. More importantly, if you are plagued by a fear of acting on these thoughts, this is a good indicator that these unwanted thoughts are most likely a manifestation of OCD rather than a sign of impending criminal or immoral behavior.

You may wonder why people are afflicted with such thoughts. In the book, Imp of the Mind, author and psychologist Dr. Lee Baer discusses how there are evolutionary reasons and societal taboos that shaped the urges in our minds to do the worst thing imaginable. There are also neurobiological factors involved that may predispose an individual to these obsessions. There are also personality traits that may increase one’s sensitivity to “bad thoughts”.

People who are tormented by their “badness” may have tried suppressing their thoughts. However, research has shown that thought suppression does not work. It’s as if I asked you to STOP thinking about a polka-dotted zebra. Stop already! Most likely, you would have trouble keeping your mind off of this creature. However, if you allowed yourself to think of and acknowledge this polka-dotted wonder, inevitably your mind would soon wander to other things.

Dr. Baer aptly names these form of OCD a “silent epidemic”, as many people think they are the only ones who suffer from such horrifying thoughts. The gold standard treatment for obsessions of this sort is exposure and response prevention (ERP). This type of therapy has been demonstrated successful in bringing relief to those suffering from bad thoughts. Cognitive therapy has also been found to be useful in treating OCD in identifying cognitive distortions that play into obsessive thoughts. Perhaps just imagining telling someone about your bad thoughts today might be the first step in helping these thoughts go away.

Treatment for Insomnia

(from a back post written in June 2014)

In my experience, patients who seek therapy for depression or anxiety often report problems with sleep. These problems usually fall into one (or more) of three categories: 1) difficulties falling asleep, 2) difficulties staying asleep, or 3) waking up earlier than intended. If insomnia is brought on by recent life stress like trouble at work or in a romantic relationship, it is called acute insomnia. Usually, this short-term insomnia resolves itself and sleep patterns return to normal. However, if insomnia persists past a few weeks (chronic insomnia), it can exacerbate other psychological problems and evolve into a vicious cycle of a) sleeplessness and b) anxious thoughts about sleeplessness. When this is the case, insomnia treatment can be helpful.

Pharmacological interventions are often used for insomnia treatment, and they can be effective. However many people find the side effects of such medication difficult to tolerate. Cognitive-behavioral therapy (CBT) is a good option for people who do not want to rely on medication. Cognitive-behavioral treatment for insomnia focuses on several key elements. The first is learning sleep hygiene principles. This involves guidelines such as going to bed and waking up at the same time every day, keeping your bedroom at a comfortable temperature, decreasing caffeine and alcohol intake, and avoiding naps during the day. Another element involves stimulus control procedures. For example, it might be tempting to watch TV or use your computer/mobile device in bed, but studies have shown that this may interrupt sleep patterns over time as you come to associate watching TV with being in bed. Limiting your activity in bed to sleep may help to ‘re-train’ your brain to pair the bedroom with sleep (rather than “TV time” or “internet time”). Behavioral interventions may also be helpful in getting a good night’s rest. Incorporating more physical activity in your day, practicing relaxation techniques before bed, and creating a pre-sleep routine have all proven to be beneficial. Studies have shown that up to 80% of patients who implemented behavioral techniques reported sleep improvements in as little as a month. A more rigorous behavioral intervention is known as sleep restriction training, which is an insomnia treatment option for those with severe chronic symptoms.

If you have worries about your sleep, cognitive techniques may also be warranted. Cognitive techniques teach you to identify and challenge any distorted thoughts about sleep, and thus free yourself from the grip of insomnia. For example, some patients think and say that not getting a good night’s rest is going to “completely ruin” the next day. One can imagine how the thought of not functioning at work can lead to feelings of helplessness and increased anxiety. However, reminding yourself that you have in fact functioned before on very little sleep and have also gotten better sleep during subsequent nights may help alleviate the anxiety around falling asleep. Similarly, one of the most important things to remember is to NOT bring your problems to bed. If you find yourself replaying the day’s events or concocting ‘what-if’ scenarios, get out of bed, write your problems down on a piece of paper, and attend to them in the morning when your brain is fully functioning.

Some patience is required in insomnia treatment, as these techniques can take time to take effect.  However, they can lead to improved and long-lasting sleep quality. Given that we spend a third of our lives sleeping, getting treatment can be a critical step in improving alertness, energy, and quality of life.

A Snippet on Dialectical Behavioral Therapy (DBT)

This is a great article on one man's journey in finding a 'life worth living.' Although a fairly "new" treatment compared to others, DBT has been found to be extremely effective for many people in moving from a place of hopelessness to one of acceptance and change. Although DBT was first created for personality disordered individuals, the different modules in DBT have also been adapted as discrete skills that can be helpful for anyone struggling with interpersonal difficulties, emotion dysregulation, or difficulties in tolerating distress. Underlying all of these skills is the ability to be mindful. As with any other treatment, DBT skills that are learned need to be practiced consistently in order to see positive effects and change. 


Panic Disorder and CBT

Panic Disorder is a serious and debilitating disorder affecting 2-3% of adults in the U.S, with women being twice as likely to be affected compared to men. From my experience, before seeking out the proper psychological care, patients who have panic disorder have usually made multiple trips to the emergency room already, fearing that they were having a heart attack or experiencing some other cardiac problem. After all, the symptoms of panic disorder can mimic those of a heart attack – dizziness spells, racing heart, unexplainable chest pains and tingling sensations. It is certainly advised that people be aware of any cardiac issues and receive medical treatment when warranted. However, if the real problem is panic disorder, getting treated by a trained CBT psychologist when symptoms begin to develop will provide the best prognosis. Understanding panic and how CBT can help may expedite the process of overcoming panic disorder in order to reclaim areas of your life affected by panic.

What are Panic Attacks?

 According the DSM-5, panic attacks are characterized by “an abrupt surge of intense fear or discomfort that reaches a peak within minutes”, with multiple symptoms being experienced in that time frame. The surge can occur even when a person is feeling calm, which oftentimes leads to more panic when there doesn’t seem to be an obvious trigger. Some of these symptoms include: accelerated heart rate, sweating, shaking, shortness of breath, sensations of choking, chest pain, nausea, dizziness, chills, tingling or numbness, feelings of unreality or detachment, and fears of losing control or dying. When panic attacks begin to interfere with a person's daily functioning in a significant manner, a diagnosis of Panic Disorder will apply. 

 Panic attacks are often maintained through ‘conditioning’, where your body and mind develops and maintains a learned “fear of fear” after a panic attack, and begins to misinterpret signals in the body as a sign of impending danger. When I talk about panic disorder with my patients, one of the first things we do together is to identify the relationship between thoughts, physiological sensations, and behaviors that trigger and maintain the panic attacks. To use a hypothetical situation, let’s say that someone had a panic attack unexpectedly after riding in an elevator, although they have usually been fine riding in elevators in the past. Because of this negative experience, they may start to fear the next time they need to ride an elevator. When that situation occurs again, they may have the thought, “I hope I don’t have another panic attack.” The physiological sensations that accompany this thought might include sweating, racing heart, and shortness of breath. This person may begin avoiding elevators, opting to take the stairs instead (i.e. altering behavior due to fear of panic). The avoidance helps decrease the symptoms related to a panic attack, but does not allow this person to learn that they can indeed overcome this fear. Understanding the connection between these components is critical in treating panic disorder.

What is Agoraphobia?

 Agoraphobia is sometimes diagnosed along with Panic Disorder, for individuals who have an intense fear of being in situations in which escape might be difficult, or fear of having a panic attack in such situations. This can prove to be quite debilitating, as people begin to fear leaving their homes, being in enclosed spaces, or riding on public transportation. If the fear of having a panic attack begins to affect your normal routine, it may be time to seek professional help.

What can I do about panic attacks?

Cognitive-behavioral treatment has been shown to be the gold standard treatment for panic disorder. Being on medication might be helpful in the short-run, but can eventually become a “safety behavior” and a means of avoiding difficult situations, and is unlikely to help you overcome panic disorder in the long run. CBT for panic disorder is not for the faint hearted – it requires persistent work, energy, and motivation to be able to challenge some of the anxious thoughts perpetuating the disorder, practice ‘de-conditioning’ to physiological sensations, and actively choose alternative adaptive behaviors that will significantly decrease panic attacks and help you to get back to your normal routine. If you are suffering from panic attacks/panic disorder, it may be beneficial to reach out to a cognitive-behavioral therapist who can help you develop skills and strategies to overcome panic.