Changing posture or covering flaws with hands or other items
Frequently starting in adolescence, BDD affects around 1 per cent of the population, and has a relatively high suicide rate compared to many other emotional problems, proving that the disorder is much more than mere vanity. BBD affects men and women roughly equally. Individuals can often spend many hours a day preoccupied with their appearance, perhaps having to get up hours early in order to work it just to feel less unacceptable.
Identifying Unhelpful Behaviours
As we note in Chapter 7, the things humans do to reduce their distress in the short term often maintain problems in the long run - so the solution becomes the problem! In the case of obsessional disorders, behaviours such as avoidance, checking, washing, seeking reassurance, comparing, readjusting and repeating (to name but a few) are the maintaining mechanisms.
Most clients we work with on their obsessional problem agree intellectually that their behaviours perpetuate and aggravate their problems, but very often they say ‘Now I really see what you mean!' after they experiment with them. Check out Chapter 4 for more information on designing CBT experiments to challenge your thinking.
The first step is to understand the concept of problem maintenance. The next step is to really experience how your behaviours affect your obsessions and preoccupation, by doing experiments.
In the broadest sense, you can try two kinds of experiment with your obsessional thinking:
Reduce (or stop) a particular ritual and see how this affects the frequency, intensity and duration of your upsetting thoughts.
Increase a ritual or avoidance for a day and see what effect this has on the frequency, intensity and duration of your upsetting thoughts.
Increasing a ritual or avoidance is often easier to do in the short term and often yields more results more rapidly.
Say you worry frequently about your house being burgled and you repeatedly check your doors and windows before leaving the house or going to bed. To find out whether your checking is part of the problem rather than the solution, record the frequency, duration and intensity of your worry about burglary on a usual day of checking. Then spend another day trying as hard as you can to double your checking, and record the results. If you note a clear increase in your worry on the day of extra checking, the ritual behaviour's clearly part of your problem.
Acquiring Anti-Obsessional Attitudes
Research and clinical observation shows that a number of thinking styles are related to the development of obsessional problems. Fortunately, you can also use thinking to combat obsessional problems. The following sections offer alternative ways of thinking that can help you in your fight against your obsessional problem.
Tolerating doubt and uncertainty
In our and many other therapists' experience, one of the main protestations that clients make about stopping rituals or avoidance behaviours is along the lines of ‘How can you guarantee that what I'm afraid of won't happen?'
The truth is, of course, that we can't. But no one without obsessional problems gets those kinds of guarantees either, so clearly the problem isn't a lack of certainty. We can offer a different kind of guarantee, however: as long as you continue to demand a guarantee or certainty that your fears won't come true, you're likely to have your obsessional problem.
Instead, practise consistently and repeatedly tolerating doubt and uncertainty without resorting to checking, washing, reassurance-seeking, or whatever you do compulsively. Your rituals only fuel your belief that you need certainty. Initially, staying with doubt may well feel uncomfortable, but if you stick with it your anxiety can reduce. Deliberately seek out triggers for your doubt and practise resisting the urge to carry out rituals, seek reassurance or work things out in your mind.
Trusting your judgement
In an attempt to explain why individuals with obsessional problems check so much more than those without these problems, scientists explored the hypothesis that people with OCD have poorer memories. The rationale here was, perhaps, that people with OCD check or seek reassurance because they can't remember properly. The scientists do make an important discovery: people with obsessional problems have no memory deficiency. What they do have, however, is poor confidence in their memory.
Poor confidence in one's memory may be related to unrealistic demands for certainty (see the preceding section on how to tolerate doubt and uncertainty), because no amount of checking removes that grain of doubt from your recall.
The best thing you can do to boost your confidence in your memory is to act as if you are more confident and cut back on rituals. Doing so consistently and repeatedly gradually helps you to build your confidence.
Treating your thoughts as nothing more than thoughts
One of the main thinking errors in obsessional problems is overestimating the importance of the intrusive doubts, thoughts and images that occur naturally in your mind. Experts in OCD have shown that the following three key misinterpretations contribute to obsessional problems:
The probability misinterpretation: The idea that having a thought about an event in your mind affects the probability of that event occurring. For example, ‘If I allow myself to picture myself hurting someone, then it's more likely that I'll do it.'
The moral misinterpretation: The idea that an unpleasant thought entering your mind reveals something unpleasant about yourself. For example, ‘Having thoughts of causing harm means I'm a bad and dangerous person.'
The responsibility misinterpretation: The idea that having a thought about an event means that you have responsibility for it happening or for preventing it from happening. For example, ‘Having an image of myself ill in a hospital bed means that I need to be more vigilant for signs of illness.'
Intrusive thoughts, images, doubts and impulses are entirely normal. Your assumption that the thoughts that you're having aren't normal is the problem. The solution is to allow these thoughts to pass through your mind without engaging with them or trying to change, suppress or hurry them along. As the song says, let it be! See Chapter 5 for more suggestions on managing your mind without interfering with it.
Being flexible and not trying too hard
If you have an obsessional problem, you're almost certainly trying too hard at something. You may be trying too hard to get your appearance or desk looking just so. Or you may be trying to ensure that you or someone you feel responsible for is safe from harm or disease. Or perhaps you're inclined to follow moral or religious instruction to the letter, rather than living within the spirit of these ideals.
Flexibility is one of the hallmarks of psychological health because it helps you adapt effectively to the real world. Consider carefully the real-life consequences of holding standards or ideals too rigidly. Do these ideals really help you live the kind of life you want? Are the costs to yourself and others worth the benefits? If not, try to define how you'd behave if you were free from your obsessional problem, or take a leaf from someone else's book and try acting accordingly. Refer to Chapter 8 for more on doing a cost-benefit analysis.
Using external and practical criteria
A crucial difference between people with and without obsessional problems is regarding the criteria they use to decide when to stop a particular behaviour. People without obsessions tend to use external observations, or practical criteria, to evaluate situations and make decisions.
In contrast, people with obsessional problems tend to use internal criteria - such as something feeling ‘right', ‘better' or ‘comfortable' - to make decisions. Here are two examples of internal criteria with their external alternatives:
A person with contamination OCD may wash her hands until she feels that her hands are clean enough. Someone without this problem may tend to stop washing when she can see her hands are clean or when she's been through a quick and convenient routine.
A person with BDD may readjust her hair, trying to reduce her feelings of anxiety and to feel satisfied inside with how she looks. Someone with
out excessive concerns about her appearance may stop styling her hair when it looks the same as usual or isn't sticking up.
Strive to use normal criteria to decide when to stop an activity. Instead of stopping when you feel comfortable, force yourself to stop washing your hands or fixing your hair before you feel comfortable. Making this change can help reinforce the fact that your criteria for stopping rituals are the problem and proves to you that your discomfort and anxiety can diminish spontaneously. Importantly, this technique can also show you that you can tolerate the discomfort of resisting your rituals.
Allowing your mind and body to do their own things
Complete control of your thoughts and body is:
Impossible: No one has it, not even highly trained doctors, athletes, monks or psychologists!
Counterproductive: Attempting to completely control your thoughts results in more of the thoughts and sensations you were trying to get rid of. You may seem even more out of control as a result.
Undesirable: Being able to completely choose the thoughts that enter your mind effectively puts a stop to any originality and creative problem-solving. Being in control of your body would almost certainly result in your demise - after all, do you really know how to run a body?
Allowing your body and mind to go on autopilot is so much easier and more helpful than trying to control your thoughts and bodily sensations.
Normalising physical sensations and imperfections
Obsessional problems like OCD, BDD and health anxiety can lead you to focus too much on your thoughts, physical sensations and minor physical imperfections. These problems also lead you to attach undue importance and meaning to your sensations, physical imperfections and upsetting thoughts.
Health anxiety leads you to attach too much importance to normal physical sensations.
OCD leads you to attach too much meaning to normal thoughts that intrude into your mind.
BDD leads you to attach too much meaning to your appearance.
Your problem isn't the content of your thought, the flaws in your complexion or the variation in your heart rate. Your problem is your belief that these experiences are abnormal. To help yourself overcome your obsessional problems, take the view that your thoughts, flaws and imperfections are normal. Conducting surveys (which we talk about in Chapter 4) is an excellent way of gathering evidence that many of the things you focus on and worry about are normal human experiences.
Facing Your Fears: Reducing (and Stopping) Rituals
In CBT, facing your fears and resisting the urge to carry out compulsions is called exposure and response prevention. This term has two important components:
Exposure: Deliberately facing up to the places, people, situations, substances, objects, thoughts, doubts, impulses and images that trigger off your feelings of anxiety and discomfort.
Response prevention: Reducing and stopping the rituals and any other safety precautions that you adopt.
In order to reduce or potentially stop your reliance on rituals, you must tackle your obsessions head-on. To accomplish this, you need to get better at tolerating doubt, allow thoughts and images to come and go from your mind, and be realistic about responsibility. And yes, you need to practise these skills!
You can make faster progress if you deliberately trigger off your upsetting thoughts and anxiety in a regular and consistent way. See Chapter 9 for more detail on designing an exposure programme to help combat your anxieties.
Facing your fears when overcoming an obsessional problem is different from dealing with many other kinds of anxiety problem because the object of your fear may be more internal than external. For example, facing the mental image of pushing someone on to a train track is just as important as actually standing on the platform.
Putting up firm resistance
To overcome an obsessional problem, you need to develop a list of your main fears as well as your typical rituals and safety behaviours.
Keeping a daily record of the frequency of the rituals you wish to reduce helps you to keep track of your progress and motivates you to keep reducing. You can record the frequency on paper or buy a ‘tally counter' (a ‘clicker' that counts each time you press it) from a stationery shop.
When you've written your list, you need to systematically expose yourself to your main fears, while simultaneously reducing and dropping your rituals and safety behaviours.
Stopping your rituals is not sufficient to overcome your obsessions. You need to incorporate deliberate exposure to your fears in order to get the practice you need.
Delaying and modifying rituals
Delaying and modifying a ritual can also be a useful lead up to dropping it entirely:
Delaying rituals. If you find stopping your rituals difficult, start off by delaying them for a few minutes. Gradually build up the time delay until you can resist a ritual long enough for your anxiety to reduce of its own accord.
Modifying rituals. If you can't gear yourself up to stop your ritual entirely just yet, modify it. Instead of going for the full-blown version of a ritual, allow yourself to perform only a shortened version. For example, if you normally vacuum every corner of a room, try making yourself stick to the areas that you can see, without moving any furniture or other objects.
Overcoming your obsessional problems is supposed to be an uncomfortable experience. If you're working through the exercises in this chapter and not experiencing a temporary increase in your discomfort, then either you're not exposing yourself sufficiently or you're not resisting your rituals sufficiently.
If you plan to stop a particular ritual but end up doing it anyway, re-expose yourself rather than letting your obsessional problem win. For example, if you have a fear of contamination, touch the floor to re-expose yourself after washing your hands.
You may be very tempted to err on the safe side and allow yourself to carry out more rituals or safety measures than the average person. Retaining avoidance and rituals can leave you very prone to your obsessions returning. Keep working at your ritual reduction until your rituals are at least as low as those of the average person on the street. Think of rituals and avoidance as the roots of a weed you're trying to get rid of from your garden. If you don't get weeds up by the roots, they're sure to grow back.
Being Realistic about Responsibility
One of the hallmarks of obsessional problems is a tendency to take too much responsibility. Individuals with OCD, for example, often take excessive responsibility for causing or preventing harm to themselves or others. A person with health anxiety may have an overdeveloped sense of responsibility for spotting possible health problems. Someone with BDD may have an excessive sense of responsibility for not causing offence or being humiliated because of her appearance. In all cases, this sense of responsibility can drive the person to carry out rituals and leave them feeling guilty if they don't.
Dividing up your responsibility pie
A helpful technique for developing a more realistic perception of your personal responsibility is to create a responsibility pie chart, as follows:
1. Identify an event you fear being responsible for (such as the house being burgled, causing harm, falling ill, being rejected).
2. Write down the level of responsibility you would feel for the event if it occurred as a percentage.
You can have between 0 and 100 per cent of the responsibility for an event occurring.
3. List all the possible contributing factors to your feared event occurring, including yourself.
4. Create a responsibility pie chart.
Use a large empty circle to represent 100 per cent, or all the responsibility for an event occurring. You can draw a circle yourself or use the circle provided in Figure 13-1.
Proportionally divide the pie into wedges, based on how much responsibility you assign to each of the factors you list in step 3. Be sure to put yourself in last.
Figure 13-1: The starting point for your responsibility pie chart.
5. Re-rate your estimation of
your responsibility for your feared event.
Use the 0 to 100 per cent scale described in step 2.
For example, Figure 13-2 shows the responsibility pie chart for Theresa, a mother with OCD who obsesses about harm coming to her children from poisonous substances. Initially, Theresa believes that she'd be totally to blame if any harm befell her children. However, after working through the responsibility pie chart activity, she's able to gain a more realistic perspective on her level of personal responsibility.
Cognitive Behavioural Therapy For Dummies Page 23