Showing posts with label psychological trauma. Show all posts
Showing posts with label psychological trauma. Show all posts

Dialectical Behavior Therapy

Earlier, I discussed emotional control through the practice of Stoicism. This article about Dialectical Behavior Therapy (DBT) goes deeper into the 'reflective' stage of that process. DBT is a type of psychotherapy that can help you to manage your psychosocial pain points; like situations over which you have no control,  common trauma response of reliving serious trauma, other post-trauma maladaptive responses, ongoing circumstantial vulnerability caused by complex trauma, etc.

Complex trauma often results from prolonged exposure to distressing events, leading to intricate psychological effects that can manifest as C-PTSD. Individuals may continue to experience symptoms such as flashbacks, emotional disregulation, and difficulties in relationships. In this context, the general public's impatient assertion that such people choose to cling to the past, to not "let go" can feel overwhelming or even invalidating, because it overlooks the depth of suffering involved. However, DBT is a more empathetic and solutions-oriented response to the suffering. The DBT approach does not imply forgetting or minimizing the impact of trauma. Rather, its compassionate take on the 'letting go' idea suggests a shift in how one relates to those experiences to foster resilience and healing. 


Interrelated Core Principles of DBT (dialectics, validation, radical acceptance) for resetting your perspective and coping:

  • Dialectics: DBT recognizes that two seemingly opposing ideas can be true at the same time. The following examples illustrate how dialectics can be applied to complex and challenging situations, allowing individuals to hold multiple perspectives and work toward integrating other perspectives to have an overall more balanced approach. This is key because focusing on the negative extreme is a human default. In fact, it is a defense mechanism to prepare oneself for potential danger. Unfortunately, it is easy to become polarized in difficult circumstances by being hyperfixated on negativity. However, dialectics is a form of de-polarization and balance (and reminiscent of the purpose of the hermetic principle of polarity; ie to become depolarized). Dialectics demands your cognitive agility. On that basis, I remember the 2 of Pentacles tarot card ... and even 5 of cups tarot card that encourages you to recognize that; while 3 cups have indeed spilt, if you turn around, you will see that 2 other cups remain un-spilt behind you and a bridge is also there to the other shore. In short, rather than see circumstances as 'either negative or positive', DBT encourages one to see challenges from the 'negative AND positive' angles. So rather than feel stuck in feeling vulnerable, you may find ways to pivot situations to say “While I am vulnerable in this situation (negativity), I am also strong (positive)” or “while I am capable of taking care of myself (masculine energy), I also need support (feminine energy).” While discussing emotional control through stoicism, I mentioned that, during a painful stoic 'pause', exploit your brain's neuroplasticity. In other words, train your mind to use dialectical reasoning to form new neuropathways. Here are some more examples.
    • Accepting a traumatic past while preparing for change in the future: 
      • A person with complex PTSD may need to acknowledge their traumatic experiences are a part of their history, while also working towards creating safer circumstances for a more hopeful future.
    • Embracing vulnerability while maintaining self-protection: 
      • Someone who has experienced trauma learns to be vulnerable and open with others (the right people), while also maintaining healthy boundaries and self-protection strategies to ensure their safety and well-being.
    • Acknowledging powerlessness while taking control: 
      • A person in an abusive situation acknowledges their powerlessness, while also taking control of their own actions and making decisions to prioritize their safety and well-being. This includes the empowerment that learning DBT and creating new neuropathways provides.
    • Practicing self-compassion while holding oneself accountable: 
      • Someone with a traumatic past is self-compassionate by acknowledging that maladaptive responses (like PTSD, anxiety disorders, dissociative disorders, cognitive distortions, social anxiety & awkwardness etc) are natural responses to their circumstances, while also learning better ways of responding to stressors.
      • A woman may feel overwhelmed and helpless due to a chronic illness. Erotical acceptance involves acknowledging the reality of her condition, accepting the limitations and challenges it brings, and focusing on her response and coping strategies, such as self-care and seeking support, rather than resisting or fighting against the illness.
    • Accepting the need for support while striving for independence: 
      • Someone accepts that they require meaningful support (like therapy or support groups), while also striving for independence and self-sufficiency (researching and shadow working on their own).
    • Recognizing the complexity of emotions while simplifying self-care: 
  • Validation: DBT emphasizes the importance of acknowledging and validating painful emotions and experiences. I must stress that if you are among those without support systems, like family, mental health professionals, police and or legal remedial services, prepare to do this for yourself.
    • A lady who has suffered trauma validates her emotions, such as anger or sadness, while also learning to counteract the distressing cognitive distortions that occur as a consequence.
  • Radical Acceptance    : Accepting reality as it is, not as you want it to be. You can neither change nor avoid the painful reality. This is a painful, hard pill type of skill that involves pulling the plug on hope of some resolution of undesirable situation. Example(s) of applications.
    • Toxic relationships. You now accept that your best efforts through overexplaining and overcompensating will NOT make a difference. These attempts never have in the past and never will. This is because the other party, abusers (whether narcissistic individuals or groups, their flying monkeys, and so on) will never stop the abuse. This is a no-holds-barred turning point of knowing that there is absolutely nothing more you can do or will try to resolve the situation. For instance, you will no longer live in hope that 'maybe after X happens, or if I just do X more, or accomplish X.' as it relates to relatives, professional colleagues, distinct social groups, and so on. Radical acceptance therefore means 1) grieving loss, often significant loss; such as hope of having a secure childhood, secure parent-child bond, meaningful friendship, marriage, acceptance in a community, working relationship, and fulfillment of dreams. Radical acceptance also means 2) you no longer hide in denial and are therefore consciously facing heavy emotions due to your loss.            Dr Ramani 'A painful look at narcissistic relationships. Radical acceptance' (above video)
    • Self-relationship. You now accept yourself fully, regardless of shortcomings, imaginary, real or set by society. This is a matter of unconditional self-love. Self-lovers see their 'imperfections' as elements of cherished uniqueness. In social circumstances, this involves not trading one's authenticity (which may simply be a difference from the social norms) to get approval from others. In other words, you are unapologietically yourself. Dr Femke Bakker used a fitting analogy of how loving parents would respond by encouraging their child who falters while learning to walk. Rather than be critical, shout at or condescend their child, they accept their child as she is in the present moment. They are patient, recognizing that their wish for a walking child will not happen overnight. This heart posture means they handle their child's daily struggle with empathy and compassion. Listen to her Ted Talk about 'self-gentleness (aka radical self-acceptance)', especially if you are driven to perfectionism in situations but are not performing perfectly. Since perfectionism is often a trauma response, the concept of self-gentleness is particularly important as you 'learn to walk' (thorny situations). Be patient with yourself. Example(s): being overwhelmed by simple tasks is not laziness but executive dysfunction; anxiety disorders is a symptom and not a reflection of your stupidity; open admittance of trauma response disorders that you had previously tried to hide through shame (by others); binging on your guilty pleasure is self-soothing / a search for a dopamine fix; neurodivergence is a symptom and not a reflection of your intelligence; etc. To be clear, this is not about being complacent with poor habits. Instead, it is a first step that can lead to positive change because openly acknowledging an issue is a way of bringing it to the forefront of your consciousness so that it can be resolved. Example(s): AA attendees usually openly introduce themselves as 'alcoholics' in group meetings in which they attempt a 12-step healing program.
    •   YouTube TEDx Talks video 'The power of self-gentleness | Femke Bakker | TEDxLeidenUniversity'
      YouTube short-form video by DoctorRue 'Radical self acceptance'
      YouTube short-form video 'Why you should practice radicatl self-acceptance'

How to apply DBT in your daily life 
Here are the 4 key components of any DBT practice. Since each component is customizable, own the design of your process so you can enjoy and remain committed.
  • Mindfulness: mindfulness practices emphasize the importance of being present and fully engaged in the present moment without judgment or distraction. Examples 
    • deep breathing, meditation (seated, guided, ecstatic dancing), progressive muscle relaxation, adult coloring books
    • Individuals with PTSD often experience flashbacks, which are intrusive memories that can feel as though they are reliving the traumatic event. Mindfulness skills can help you to stay grounded in the present moment. Examples. You can practice the “5-4-3-2-1 technique”. This requires you to focus on your 5 senses by identifying: 
      • 5 things they can see around them,
      • 4 things they can touch,
      • 3 things they can hear,
      • 2 things they can smell, and
      • 1 thing they can taste.
By focusing on these sensory experiences, you redirect your attention away from the flashback and back to their current moment, reducing the intensity of the trauma-related symptoms.

  • Distress tolerance skills. To describe this practice in short form; it is about accepting pain without unnecessary and additional suffering. This is achieved by using healthy distractions. These healthy destructions help you to select thought patterns that are better than ruminating and causing intense emotional suffering and to be clear healthy distractions are not the same as avoidance. Examples.
    • Self-talk in your head or allowed when triggered as by the news or when hearing about or from someone who caused you pain. 
      • I cannot change what has already happened. [Do not relive the painful moments trying to figure what you should have or could have said or done instead Develop some type of releasing, aka 'defusion', like imagining the memory as a black balloon that you release into the wind as you redirect your focus to something else, perhaps a white or colorful balloon with something specific .... Or you can focus intensely on the present moment.]
      • This moment is the outcome of multiple turns in the past do not agonize over 'what-if' scenarios like if you had just returned the call the night before, given x detail and so on.
      • Read about Mel Gibbon's What if it all works out mantra that frees her brain from focusing on only the worst, most catastrophic of multiple probabilities 
    • To cope with nightmares through Distress Tolerance Skills. self-soothing is a form of distress tolerance to cope with overwhelming emotions and situations without resorting to avoidance or harmful behaviors. This involves engaging in calming bedtime routine activities like:
      • taking a warm bath,
      • Listening to soothing music,
      • Practicing deep breathing exercises
      • Using aromatherapy
      • Declaring sleep time intentions 
    • In acute distress situations that might trigger dissociation, use these distress tolerance steps.
      • Step 1: Identify a distressing situation or feeling (e.g., feeling overwhelmed by memories).
      • Step 2: Use the “TIP” technique (Temperature, Intense Exercise, Paced Breathing) to manage acute distress:
        • Temperature: Splash cold water on your face or hold ice cubes; this can help anchor you to reality.
        • Intense Exercise: Engage in physical activity like jumping jacks or running in place for a few minutes.
        • Paced Breathing: Practice slow, deep breathing like 'box breathing' to calm the nervous system.

  • Emotion Regulation Skills: Strategies such as identifying and labeling emotions, understanding emotional triggers, and using coping skills to manage emotions.
  • Interpersonal Effectiveness Skills: Techniques such as active listening, assertiveness, and boundary-setting to improve communication and relationships.
    • Assertiveness in interpersonal relationships might help you if you fear rejection or misunderstanding (that might arise from expressing your needs or feelings). Use “I” statements to express your needs and feelings (ie versus'you' statements). Example; Instead of saying, “You never listen to me,” say, "I really need to be allowed to complete each idea without interruptions/ for someone to take action on XYZ / the direct communication I" or “I feel ignored when I share my thoughts but [describe the person's triggering behavior] like do not get any kind of response.” If the counter party is worthy, this approach is likely to be received as not blaming them.
    • Unapologetically set boundaries to prioritize your mental health while remaining being polite and respectful towards others. Example; say, “I appreciate the invitation, but I need some time for myself right now or I need time to think about that before committing or I needed the scores from your professional observations so I can keep track and really engage in my progress.” 
    • Assuming that the other person is worthy and has good intentions but does not yet understand how to meet your needs, say "If someone does x (like grab me suddenly), that makes me feel  unsafe because it triggers my anxiety.


Who Can Benefit from DBT:

  • People with post-traumatic stress disorder (PTSD): DBT can help individuals manage symptoms of PTSD, such as flashbacks, nightmares, and avoidance behaviors.
  • Anyone seeking to improve emotional regulation and relationships: DBT can be beneficial for individuals looking to enhance their emotional intelligence, communication skills, and overall well-being.
  • Those struggling with emotional dysregulation: DBT can help individuals manage intense emotions, reduce self-destructive behaviors, and improve relationships.


CONTENT RELATED TO DIALECTICAL BEHAVIOR THERAPY


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Complex Post Traumatic Stress Disorder (C-PTSD) vs PTSD

Previously, I discussed PTSD. However, his post will focus on a more severe cousin, Complex PTSD. Complex post-traumatic stress disorder, aka c-PTSD is an anxiety disorder that can be considered an overall more severe form of PTSD because, in addition to the standard PTSD symptoms, it features additional ones. Before continuing, it should be noted that, some mental health professionals make a distinction between PTSD and CPTSD in line with the 2018 decision of the World Health Organization (W.H.O) to include C-PTSD as its own separate diagnosis in the 11th revision of the "International Statistical Classification of Diseases and Related Health Problems" (ICD-11). However, as at 2022, CPTSD is still not recognized as a distinct disorder in the DSM-5 (the US diagnostic manual), forcing only the diagnosis of PTSD in the US, with  mild, moderate, severe and where patients may need to stress the additional criteria to emphasize the greater level of severity. 

The classification of the PTSD and c-PTSD under 'Trauma & Stressor-Related Disorders' indicates a coping response to trauma and stressors, usually intense trauma like rape and torture. 


Causes of C-PTSD
It is believed that C-PTSD is the result of severe, prolonged and repetitive abuse when the victim is vulnerable, disempowered and unable to escape, like childhood. In other words, it is the result of a series of ongoing traumatic events, commonly associated with the following list. Furthermore, the harmful effects of items on the list can be compounded within the context of oppression and racism, especially if the justice and other highly influential systems and institutions are involved or facilitating in this abuse.
  • Child abuse, neglect, or abandonment
  • Torture
  • Slavery
  • Domestic violence
  • Genocide
  • Childhood soldiering
Traumatic stress can have a number of effects on the brain. Research suggests that trauma is associated with lasting changes in key areas of the brain including the amygdala, hippocampus and prefrontal cortex.


C-PTSD versus PTSD
Here is a contrast between CPTSD and PTSD.

CPTSD
  1. caused by repeated, inescapable, ongoing series of traumatic events over the long-term. The abuse may occur systematically (ie versus as a single, well defined event with a start, middle and end point). This is particularly the case with interpersonal relationships in which the sufferer feels disempowered and their sense of security is jeopardized. Offensive behavior is very personally directed against the sufferer. Needless to say, key terms include disempowerment, unsafety. 
    • The events may collectively create a life with a pattern of trauma like a rape at age a and then at age b, witnessing a murder at age c, being in a life-threatening accident at age d and then experiencing continuous abuse at work. (Many people only experience 1 event and even if they experience multiple events, they are usually able to fully recover from the first before others occur).
    • People with daily activities that are potentially life threatening or otherwise dangerous may not only experience their own suffering but even their children who fear for the safety and life of their loved one each time they leave home. The children may have panic attacks, especially if the loved one has already had a real event.
    • People who have already had major health issues that involve numerous traumatic events scares that can recur can suffer. For instance, during the course of treating an illness; patients might have relapses, medications might provoke bad reactions, the patient and caregivers may make mistakes and so on.
  2. typically occurs in childhood (a time of greatest vulnerability, especially if without a support system)
  3. usually more intense than PTSD
  4. often associated with oppression, racism, subsequent chronic mental and physical health issues like serious anxiety disorders, depression disorders, dissociative disorders, fibromyalgia, diabetes, heart disease, a compromised immune system, feeling intensely separate from others, digestive problems, perfectionism, limerence, addiction (to substances to numb and regulate negative emotions). There is greater functional impairment than in the case of PTSD. The brain structure begins to change because people suffering ongoing feelings of disempowerment lose hope.


PTSD
  1. caused by one-off traumatic event like an accident, a terrorist attack, being raped as a one-off incident (ie versus repeated rape over several years, as by a primary caregiver)
  2. can occur at any stage in life
  3. usually milder than CPTSD


Effects of C-PTSD (vs PTSD or ASD)

C-PTSD is very isolating because others have trouble understanding the continued struggle. This lack of understanding is possible even among others who recovered from PTSD, thanks to the singular nature of their challenge and support, not only from family and friends but even from the wider community and justice system. Needless to say, the average person in the population (who has, at the worst already recovered from their acute stress disorder / ASD) is even less likely to understand. 

The intensity of the suffering of a vulnerable person without the wherewithal to overcome the circumstances, like a small child with long term abuse from primary caregivers and others in the community who exploit the child's obvious vulnerability is a greater burden to overcome. Consider the fundamental differences between people carrying complex trauma versus those who are not with the analogy offered by CTAD Clinic, Dr Mike Lloyd (Consultant Clinical Psychologist and Clinic Director) @02:30 in his following video. Dr Lloyd likens the average person without the ongoing burden of trauma to hardy dandelions. They survive harsh sunlight, heavy rain, transplantation to different environments and so on. Conversely, the orchid is fragile and needs a very special set of growing conditions in order to survive and even thrive. The case of the orchid is not lost, just a special one that requires special attention. CPTSD sufferers should therefore focus on learning what they need, usually safety is a key component.


Symptoms of C-PTSD (that exist in addition to PTSD)

In addition to all of the core symptoms of PTSD (re-experiencing, avoidance, and hyperarousal), C-PTSD symptoms generally also include the following to a life-altering extent. (See video below about re-experiencing)

  • Negative self-view, aka cognitive distortions, maladaptive thoughts, errors in thinking or irrational thoughts refer to very unpleasant thoughts that are extreme and arguably inconsistent with reality. As a result, such negative thoughts can negatively influence mood and lead to unhealthy behaviors (like isolation and other forms of avoidance because solitude is attractive over having to deal the dangers inherent in dealing with others). When child abuse CPTSD sufferers experienced such complete defenselessness and powerlessness, it is no wonder they feel like this. 
    • When one views him or herself negatively, their thoughts might be of helpless, hopelessness, guilt, or shame, feeling unlovable, feeling alien from others
    • Constantly feels unsafe or a heightened preoccupation with safety. This is coupled with fears of the potential occurrence of absolute catastrophes. Tendency to create a routine that is planned to manage every detail with multiple backup plans to safeguard against adversity. 
  • Dissociative disorders and detachment from one's own experiences (emotions, health, etc). While these phenomena occur with PTSD, the incidence is much greater among those with c-PTSD. Consider the fact the PTSD symptom re-experiencing (aka intrusions) involves the instantaneous 'fronting' of a fragmented part of one's past self wanting to protect the main person. Consequently, complex trauma provides far more opportunities of this type of fragmentation to occur. Triggers can make a person disconnect from themselves (depersonalization) and the world around them (derealization) or some other form of dissociation. Triggers can make a person even forget their trauma (dissociative amnesia).
    • A child who was repeatedly raped by primary caregivers and community members recognizing that child's vulnerability over extended periods is more likely to dissociate in order to survive daily life (ie in comparison with someone who was raped once by strangers or acquaintance but had support from family, friends and the justice system).
    • numbness, ignoring or denial of illness which imitates lacking concern of authority figures during the abuse and their corresponding response to survive.
        
  • Nervous system dysregulation. While a healthy nervous system is able to calm down shortly after some stress-inducing trigger, an unhealthy nervous system has a very delayed recovery period. See video on nervous system dysregulation.
    • Two people are startled by something. Both experience abnormal breathing in the moment. While the one with a healthy nervous recovers normal breathing and reverts to an overall state of calm within seconds or minutes at most, the person with an unhealth nervous system continues to demonstrate signs of anxiety for hours or even days.
  • Difficulty controlling emotions. Triggers can commonly provoke sufferers to lose control over their emotions in one of several ways, like explosive anger, persistent sadness, depression, and suicidal thoughts.
    • Having been blamed in an overly harsh way for extended periods, always fearful of being targeted for ill treatment, left to fend for oneself as a child and so on, C-PTSD sufferers may handle conflict with inappropriate emotions and levels of emotion. The reactions may appear excessively aggressive to others.
    • Long term concentration camp survivors may have excessively loud, anxious  reactions if someone hits them unexpectedly from behind many years afterwards.
  • Difficulty with trust in relationships. Relationships may suffer due to difficulties trusting others and a negative self-view. A sufferer may avoid relationships or develop unhealthy relationships because that is what they knew in the past.
  • Major change in world view, aka 'loss of a system of meanings'. This can include losing one's core beliefs, values, religious faith, or hope in the world and other people. One's world view may become negative.
    • The impression of how the world works and the lack of understanding of the sufferer's circumstances can lead sufferers to feel that there is no place in the world for them, that they do not fit in anywhere.
    • You may no longer feel capable of overcoming obstacles but as if your hands are tied behind your back by external forces, like a racist judicial system, a corrupt authority figures and so on.
    • Sufferers are more observant and aware of the potentially threatening stimuli in the world than the average person.

 


Treatment
The key elements for recovery is to restore a sense of safety and empowerment, reintegration of fragmented parts of self, including the parts stuck in the fight or flight mode of the brain's amygdala and relational security.

In addition to the treatments sought for PTSD, the following are used for c-PTSD.


Common mis-diagnosis
Beware, C-PTSD is most commonly misdiagnosed as borderline personality disorder. However, keys ways in which CPTSD and borderline personality disorder (BPD) differ are that the following.
  • C-PTSD sufferers tend to be avoidant of relationships while borderline personality disordered persons are more concerned with abandonment issues.
  • C-PTSD sufferers tend to have a distorted sense of self while BPD sufferers have trouble with a sense of identity, something different.
  • C-PTSD sufferers are less likely to be suicidal while suicide has a stronger likelihood.
  • C-PTSD sufferers have an extremely strong likelihood of significant childhood trauma while this is hardly the case with BPD sufferers.


CONTENT RELATED TO COMPLEX POST TRAUMATIC DISORDER (c-PTSD)

 


Challenges with mental health and fatigue from masking neurodivergence are clues that helps in recognizing neurodivergence, especially for boomers and generation Xers. 

 

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Obsessive Compulsive Disorder OCD

Obsessive Compulsive Disorder OCD

Obsessive Compulsive Disorder or OCD is a mental health disorder that features unwanted thoughts and fears (ie obsessions), leading to repetitive behaviors (ie compulsions) that are extremely disruptive to one's life beyond the general population's  normal levels of obsession or compulsivity (ie a disorder). OCD may be understood as a disorder of doubt or uncertainty because it is based on sufferers trying to regulate something that is not necessarily true or highly improbable. Sufferers are therefore trying to make certain that they remove uncertainty.

In this post, I will discuss each of the 2 diagnostic required components of this disorder; obsession and compulsion.


Obsessions

Obsessions are recurring thoughts, images or urges. Unfortunately however, they are disturbing, unwanted and intrusive. In other words, the unpleasantness is unwanted. The person therefore feels that the obsessions are out of his or her personal control which renders feeling of some level of powerlessness. When OCD sufferers struggle with obsessive intrusive thoughts without a corresponding physical compulsion, the condition is referred to as "Pure O" (to mean only obsessions'). To be clear, pure O is NOT a different diagnosis according to the DSM5.

A very important feature of obsessions is that they trigger distressing feelings. Those feelings are usually related to fear, disgust, doubt or the idea that something must be done in a very specific way. Regardless, this distress triggers the fight or flight response. So rather than have a trigger like war or rape, the same trigger will have occurred within the minds of OCD sufferers.

Pure O sufferers feel particularly stressed because the thoughts deviate so much from their normal values and beliefs that they are fearful that something within themselves has changed and they may feel compelled to act accordingly. Pure O obsessions usually take the forms of thoughts about physical or sexual aggression, visualizations of inappropriate images and frightening impulses.  

Another feature is the repetitiveness of the obsession.

To be clear, they are irrational or based on low probability outcomes. For instance, while extra handwashing during the Covid-19 pandemic was based on a rational, probable fear of contracting the disease, a fear of contracting Ebola in most cities is not very probable. 

Common obsessions include the following. 

  • Contamination obsessions. Fear of contact with perceived contaminated things like body fluids (examples include urine, feces); Germs/disease (HIV, COVID-19); Environmental contaminants (asbestos, radiation); Household chemicals (cleaners, solvents) and Dirt.
  • Violence obsessions. These involve the fear of: acting on an impulse to harm oneself or others or; violent or horrific images in one's mind
  • Responsibility obsessions. Fear of being responsible for: something terrible happening (like fire, burglary, car accident); harming others because of not being careful enough (dropping something on the ground that might cause someone to slip)
  • Perfectionism-related Obsessions. Excessive concern about: things not being even or exact; not knowing or remembering; losing or forgetting important information when discarding something; performing tasks "perfectly" .
  • Sexual Obsessions. Unwanted thoughts or mental images related to sex, including fears of: acting on an inappropriate sex-related impulse; sexually harming or being aggressive towards others like children, relatives.
  • Religious/Moral Obsessions (Scrupulosity). Excessive concern with: offending God; damnation; and/or concern about blasphemy.
  • Other circumstance-related obsessions. 
    • Obsessions about death/existence (like excessive preoccupation with existential and philosophical themes, such as death, end times. 
    • Emotional contamination obsessions (like fears of "catching" personality traits, perceived level of luck of other individuals
  


Compulsions

Earlier, I mentioned that distress accompanies obsessions. The distress  needing more cleanliness, sense of moral responsibility to avoid doing something to harm others and so on are the driving motivations for compulsions. Compulsions are repetitive behaviors or thoughts that one uses to try to neutralize the obsession-related distress. A key feature is repetition. 

Ironically, OCD sufferers know that compulsions are only temporary fixes. However, without immediate alternatives, they rely on the temporary fix anyway, much like emotional eating, thoughts to cancel out the initial negative thought.

Common examples include the following.

  • repeatedly going in and out of doorways, even at the known risk of running late for important engagements.
  • re-checking the stove several times before leaving the house
  • re-checking that objects are set down correctly in their place, like a CD into the tray of a carousel.
  • scrubbing oneself until the skin is bruised.
  • nervous tics like eye blinks, nose twitches, grimaces, shoulder shrugs, heard jerks (ie simple motor tic-related OCD or 'tourettic OCD' but not really tourettes which responds to physiological triggers versus psychological ones)
  • refusing to drive or be driven for an accident. In such case, the fight of flight response is heightened.
  • re-checking safety packaging for contamination.
  • hand washing until the skin is dry or peeling
  • seeking reassurance numerous times about the safety of a route
  • thoughts to cancel negative obsessive thoughts


It must be stressed that the heightened sense of responsibility to neutralize the obsession is not only a key diagnostic feature but also an indicator that even sufferers have a strong conscience and are highly improbable of acting on obsessions like harming others. OCD sufferers obsess in fear that they will act on their bad thoughts (than humans all have). Others should therefore exercise care in considering obsessions as a potential for criminality. The difference between OCD sufferers and someone with an antisocial disorder is that the latter does not exhibit the second OCD component, compulsion (ie to neutralize the obsession). A criminally minded person may enjoy the obsessive thoughts and actually act on the obsession. Regarding pure O, I mentioned earlier that there may be no corresponding behavioral / physical compulsions. However, there may be cognitive compulsions. For instance, sufferers may ruminate, usually a lot more than usual.

Sometimes, when the obsession is not very well understood, it may be useful to consider that compulsions often correspond to specific types of obsessions. The following are common examples that might help in better understanding the obsessions and their underlying psychological challenges.


Obsession: ===========> Compulsion

Unsafety ============> Cleaning

Fear of bad situations ====> Repetition

Painful thoughts =======> Saying good thoughts



Obsession and compulsion must be disordered

Diagnosis requires that obsession and compulsion be disordered. 

In the population of non sufferers, using these terms, people speak of "obsessing" over something, like a new social media influencer and will never miss a single new episode. It is also normal for people to double check what they have done. However, these types of so-called 'obsession' do not meet the diagnostic criteria because they do not feature the 2 components. For instance, following the influencer and simple double-checking do not disrupt life as one can still easily meeting meet life obligations as normal, like work and other social situations. 

However, someone whose obsession and compulsion make them not only double check like normal but to re-check 3, 4, 5 or more times is disordered because these additional checks consume extra-ordinary amounts of time and ultimately disrupts their lives as sufferers always arrive late or other socially unacceptable behavior. Despite recognizing the risk of running late for engagements, sufferers prefer to perform their rituals.

For diagnosis, the DSM-5 requires 

  • observation of obsession, compulsion or both. In the case of 'pure O', ie only obsession OCD involves obsessive thoughts that are not followed by physical compulsions.
  • compulsion should be time-consuming
  • disorder must NOT be explained by physiological effects of substances or other medical condition
  • should NOT be better explained by another disorder 




Incidence & Triggers

OCD affects roughly 3% of the population and usually develops during childhood or adolescence between the sexes equally. Persons seeming most prone to OCD are those that are intolerant of uncertainty. It is likely that OCD is most likely during stressful periods (like starting a new job, moving country and so on). 

Stress of any type, positive or negative can trigger OCD.

Famous persons suffering with OCD include David Beckham, Howie Mandel and Howard Hughes.


Other observations
OCD sufferers often exhibit higher levels of irritability. This is because their minds are already very preoccupied with fears that their capacity for tolerance to manage the normal amount of irritation is compromised. 

If possible, sufferers may become avoidant of social situations  because of fear that their rituals will likely illicit ridicule from others. (Read about social anxiety disorder / SAD)


Treatment

Treatment involves the following, often but not necessarily in combination. The purpose of treatment is to return the sufferer to a normal life experience.

  • psychotherapy aka talk therapy that helps sufferers to better manager their thoughts. It is best to pursue this type of treatment with only persons that are specially trained and experienced, like OCD experts, persons registered on the directory of professionals with OCD expertise via the International OCD Foundation (OCDF)  website, directory of professionals via the Anxiety & Depression Association of America, the Advancement of Behavioral & Cognitive Therapy (ABCT). Even specialized OCD support groups may exist. Treatment often includes 
    • safe exposure therapy, ie the sufferer is exposed to the obsession to retrain the mind into recognizing the irrational nature of the obsession. This usually reduces the distress associated with the obsession. However, the gold standard is exposure response prevention (ERP) form of treatment. The therapy requires the sufferer to sit with their anxiety in a safe place until the anxiety can subside, with a diminishing effect similar to reviewing the same scary movie repeatedly, ie 'habituation'. Another approach is that sufferers may also be encouraged to attempt dissociating themselves from the obsession and then responding to it saying "no", "no, x will not happen", etc ... The aim of responding this way is to develop a internal voice that overpowers the obsession in time. Visualization is yet another approach. For instance, one may visualize the obsession as a passing cloud. These methods may be used alone or in combination. Yet another approach is called cognitive restructuring (video below) based on calling out one's cognitive distortions to oneself.
  • medication that slows down the over activity in the affected parts of the brain. 
    • Selective Serotonin Reuptake Inhibitors / SSRI



CONTENT RELATED TO OBSESSIVE COMPULSIVE DISORDER (OCD)

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Anxiety Disorders

In a different post, I discussed the decision-making and preparation for getting help for psychological concerns. In that post, I used the example of major depressive disorder (MDD) and bipolar disorder types 1 and 2. This post continues that discussion by briefly discussing common types of anxiety disorder (Social Anxiety Disorder / SAD).

Anxiety is a normal human reaction to stress and danger. However, when it occurs beyond the normal extent and even forces the sufferer to alter their life (to avoid the fear), it is considered 'extreme' and called a 'disorder'. However, the term 'anxiety disorder' collectively refers to a group of mental health problems. Each anxiety disorder has its own unique features and is therefore treated accordingly. The most common forms and their approximate frequency within the population include the following. It is also possible for single individuals to have multiple forms. However, in order to arrive at such a scenario, it is necessary to pay special attention to the subtle differences such as the particular objects of fear. After all, there are subtle elements that overlap between types of anxiety disorder. In short, it is a matter of finding the best fit. Furthermore, in all cases, the disorder should not be explained by extraneous factors like drugs or other illnesses that cause anxiety.

  • specific PHOBIA, 8 to 12% of the population.. Specific phobias refer to the irrational fears of a specific object or situation. Phobias (including agoraphobia discussed below) are an extreme type of fear to the extent that they are no longer considered a mere 'fear' (much like how 'anxiety disorders' surpass the significance of normal human 'anxiety'). Sufferers catastrophize, ie they assume that the probability of a negative outcome is nearly 100% (when in reality, it might be very small). Since sufferers feel powerless against these phobias, they may go to great lengths to avoid exposure. Exposure commonly results in exaggerated responses like trembling, sweating to an extent that exceeds their norm and so on. Unlike fears, phobias, disrupt daily life. This is what differentiates normal levels of anxiety from anxiety disorder. 
Treatment commonly include carefully planned safe exposure to the trigger. This exposure may even be through imagined or virtual reality exposure, especially when real exposure is impractical. Based on an hierarchy of phobias, triggers may be prioritized for treatment if there are multiple ones. Another type of treatment is cognitive restructuring. This involves addressing the irrational nature of the phobia, like assuming an abnormally high probability of a worst-case outcome.

Example(s) of phobia.
    • Medical. 
      • hemophobia is the fear of blood or needles.
    • Situational: 
      • Agoraphobia is the fear of being helpless and trapped in a situation. Escape may be either difficult or embarrassing.
    • Environmental: 
      • claustrophobia is the fear of enclosed spaces.
      • urban phobia is the fear of cities or urban environments.
    • Animal-related: 
      • Ophidiophobia is the fear of snakes.
      • Arachnophobia is the fear of spiders.
  • agoraPHOBIA, 1 to 3% of the population. Agoraphobia is the fear of being in public places from which escape would be difficult if needed. Essentially, it is a fear of being trapped. This fear is commonly associated with public places from which sufferers wish to escape back to a safe space like their homes. Such people tend not to venture out much. This phobia may have developed as a result of an unresolved panic disorder.
    • Fears of crowd; like in music concerts or shopping malls
  • social anxiety disorder (SAD, aka social phobia disorder), 7% of the population. SAD is the overwhelming concern of being humiliated, ill-treated or embarrassed in social situations. While all humans fear humiliation, harsh judgement, feel shy at times and so on, SAD exceeds those experiences beyond the normal levels. Unlike agoraphobia (where the fear relates to being physically trapped), sufferers fear socially difficult situations. In order for this intense experience to be considered a disorder, it must affect normal routine and relationships. Additionally, the problem must be persistent, specifically at least 6 months. The social situations may vary by person.  For instance, for some individuals, the anxiety is triggered by public speaking at work, for others, it may be meeting new people and so on. The situation may become compounded by the fact that, being aware of their affliction, afflicted persons may then develop the additional fear that others can detect the affliction. In some severe cases, persons also experience derealization.     
    • While anxiety occurs normally when meeting new people before diminishing and entirely going away after becoming more familiar with those erstwhile 'new' people, someone suffering with SAD continues to suffer the same heightened level of anxiety, even after becoming better acquainted. This therefore extends beyond the norm. Furthermore, if the impact is some type of avoidant behavior that disrupts his or her life, perhaps he or she no longer seeks to meet new people and keeps a distance from others, then such a person can be said to be suffering from SAD.
    • Fear of eating in front of others even despite familiarity.
    • Fear of public speaking that continues, even several hours after the speech has occurred.
  • panic disorder, 2% - 3% of the population. Panic disorder is characterized by recurrent panic attacks. A panic attack is normal experience that happens to most people at least once in their lives. It is a sudden and intense feeling of fear that something bad will happen. It manifests anxiety in its most severe form. Panic attacks are an aspect of the fight or flight response. These attacks are so intense that there are even physiological signs like heart palpitations, shortness of breath and sweating. They may last between a few minutes or, in more severe cases, several hours. Patients often think they are having a life threatening experience like a heart attack. The DSM-5 stipulates that patients can be said to experience a panic attack if they observe at least 4 (of 13) criteria. Sufferers can be diagnosed with the disorder if i) the attacks are recurrent and unexpected, ii) the patient worries persistently and changes behavior (because of the attacks). Attacks can not be attributable to drugs or other substances (and can not be explained by other types of phobia like agoraphobia, etc). Since attacks are unexpected, patients must be treated before they begin to shut down by altogether in seclusion by avoiding places where attacks occur. Panic attacks often occur along with other disorders. 
    • Palpitations, pounding heart, or accelerated heart rate
    • Sweating
    • Trembling or shaking
    • Sensations of shortness of breath or smothering
    • A feeling of choking
    • Chest pain or discomfort
    • Nausea or abdominal distress
    • Feeling dizzy, unsteady, lightheaded, or faint
    • Feelings of unreality (derealization) or being detached from oneself (depersonalization)
    • Fear of losing control or going crazy
    • Fear of dying
    • Numbness or tingling sensations (paresthesias)
    • Chills or hot flushes
  • generalized anxiety disorder (GAD), 2% of the population. GAD is an exaggerated feeling of uneasiness of impending doom. Unlike other forms of anxiety, such as social anxiety disorder or agoraphobia that deal very specifically with social situations or physical spaces respectively, GAD has a broader set of triggers. Some such triggers may include the following. finances, physical security, etc. Signs and symptoms include edginess / restlessness, mind going blank, irritability, difficulty concentrating, digestive problems (from over or under eating), muscle aches (from anxious tension) and sleeping problems (which can often lead to chronic fatigue). As with other forms of anxiety, the disorder affects the normal course of life. However, in severe cases, the disorder is entirely debilitating, leaving the afflicted person unable to perform the simplest daily activities. Since the level of severity exists on a continuum, persons with mild cases can be able to function socially in a job for instance. However, the levels can worsen or improve over time. For an official diagnosis, the worry should extend for at least 90 days out of 180 days (ie more than half of the time). The person must have trouble calming themselves down (ie self soothing). (Only 1 of these symptoms is required for the diagnosis in children). Common evidence of this disorder includes: difficulty going to school or work.   
  • Separation anxiety disorder. This involves fear of losing someone to whom one is attached.
  • Post Traumatic Stress Disorder / PTSD has been reclassified in the DSM-5 from being an anxiety disorder. One way in which it can be seen as different is the fact that it involves an external event. Read more about PTSD.


If you have not yet been diagnosed but have done research and have suspicions about certain conditions, research its official definition and associated list of symptoms in the Diagnostic & Statistical Manual (DSM) used by mental health professionals. Note those symptoms that you observe in yourself. It is useful to consider clear examples. As you will notice from the DSM, conditions apply only if you have the 'A criteria' (ie those criteria that you must definitely have in order for the condition to apply at all) and meet the minimum number of symptoms. In other words, if these criteria are not met, there is no need to proceed further with the particular condition.

The 'A' criteria for anxiety are at least 3 of the following signs and symptoms.
  • restlessness
  • easily fatigued
  • difficulty concentrating
  • irritability
  • muscle tension
  • sleep disturbance


CONTENT RELATED TO ANXIETY DISORDERS
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