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Welcome back, everybody. Thank you so much for joining me. I know your time is so valuable, and so I am so honored to spend this time with you to talk to you about today common question that I get asked. Well, actually, no, it’s not a common question, but it has been a question that I have been asked over the years by clients and followers, and listeners. And I was proposed with this idea as something that we really need to address. And so, here I am. And my goal is to always address the things that maybe aren’t getting addressed if possible. And so, today we are going to talk about, what if I don’t fit into the typical OCD subtype? So, what if my obsessions don’t line up with the typical classifications and categories that we have for OCD?
So, for those of you who maybe are new to this idea, we have OCD as a general diagnosis. And then under that umbrella of the diagnosis, we have-- over the years, the clinical and OCD community have created subtypes of OCD to help us, number one, categorize different groups of obsessions so that we can then direct the treatment to being very specific. We also do that to build a sense of community so that you feel less alone. Let’s say you have a harm obsession that can be very stigmatizing and feel very, very overwhelming, and you can have a lot of guilt and judgment about that for yourself. So, knowing you’re in a category, in a group with other people can actually soften the blow of the stigma and the judgment around that obsession. Same goes for sexual obsessions, pedophilia obsessions, and so forth.
Again, as a clinician, as I’m training my therapist, these subtypes are actually helpful so that we can help the newer therapists have a treatment plan specific to that person’s obsession. However, what about the group of people who don’t line up perfectly in those groups? And so, in today’s episode, we’re going to talk about what to do if that is you, what to do if you’re a therapist and you’re dealing with this, some skills that you might use, and maybe a few shifts and reframes here, I’ll use some clinical research that may help you shift the way you look at this problem. And maybe we can even stop calling it a problem. We could actually not address it as a problem and actually move through that together. Okay?
Before we do that, let’s get straight to the “I did a hard thing.” I haven’t even read this hard thing you guys, so I’m as excited as can be. This one is from Hannah, and this is what Hannah had to say:
“Earlier this year, I suffered a debilitating OCD episode that focused on harm OCD,” so, there we are, we have a subtype already explained, “Specifically the fear of sleepwalking or going crazy and harming my family. At the time, I had no idea I had OCD as I had always been told I was just an anxious person. So, this well and truly threw me to the point that I couldn’t get off the couch, take my daughter to and from school or be alone. I wanted to admit myself into a mental health facility for fear that I was a real danger to my family and my daughter in particular. Long story short, after weekly ERP with a therapist and starting an SSRI, I did a very hard thing by being at home alone with my daughter for a whole weekend while my husband went away for work. I don’t think I’d be able to do it and I had been feeling anxious for months prior to knowing it was coming. But I did it and I actually ended up enjoying our time together despite some fairly consistent rumination.”
Hannah, oh my gosh, this is so good. You are such a walking billboard for how effective ERP and medication can be. I love that you did this. This is so good. And so, congratulations. I am so honored that you shared that with us. And look at you go. Look at you go.
All right. Again, quickly, let’s do the review of the week. This one is from Austin-mang, and they said:
“I finally did it and signed up for therapy. My session is this Friday. I’ve been doing my best to prepare and was uncertain about what to expect my first session. This show helped me to know exactly what to expect and gave me some great mindset tools going in. Thank you!”
Austin-mang, it sounds like you did a hard thing too. This is so wonderful. So, thank you guys for sharing your hard thing, and thank you so much for leaving a review. It does help me immensely build trust for those who are new to the show.
All right, let’s get to it.
So, let’s backtrack to the main concern here, which is what if I don’t fit into a typical OCD subtype. Now, this is a hard thing for people, because not falling into that subtype can make it hard to be diagnosed. I was just thinking about this yesterday. Ten years ago or longer when I first started treating OCD – it’s been nearly 15 years now – if you typed into Google “What if I harm my baby,” maybe one or two articles would come up, but you would find an article about OCD and then you would slowly, if you’re able, get to treatment. Remember, our mission here is to reduce the amount of time it takes someone with OCD to get diagnosed and treated. Right now, it’s seven to 14 years, which is absolutely horrendous, but we’re getting better. We’re getting better.
So, if you typed in “What if I harm my baby” or “What if I sinned,” you would probably come to an article that may lead you to, you may have OCD. What if I get sick and die? If you typed your what-if thought into Google, you’d probably find an article somewhere. But there are a group of people who if they typed their fear in, OCD would never come up. It would never show up on a Google search. If you told your doctor, they might not be able to identify this as OCD, because as far as we’ve come with educating, these subtypes have actually helped us educate doctors, nurses, teachers, and caregivers so that they can be more likely to pick up on children’s and young adult’s OCD. As much as we’ve done this, if you don’t have those specific subtypes, it can make it very difficult to get diagnosed.
The next piece here is a lot of people, and this is what I really hear a lot in my community online, on Instagram – if you follow me on Instagram, it’s @YourAnxietyToolkit – is some people will say, “Because I don’t fit into this subtype, I have a lot of doubt that I have OCD at all.” We know OCD is a doubting disorder, but often people with OCD even doubt, even if they fit into a subtype, they doubt that they have OCD. But if you don’t fit into one of these categories that we’ve put, these loose categories that we’ve put, that can make it even harder to really double down with your treatment and feel confident in your provider and feel confident in your diagnosis and so forth.
There is a lot of times when people don’t talk about their specific obsession, when it doesn’t fall into that subtype in fear that someone would say, “You don’t have OCD. You don’t follow any of the subtypes.” And I’m sure maybe even some uneducated clinicians have shared that with their clients like, “No, you don’t meet criteria because you don’t meet a subtype.” And hopefully today we can actually get rid of that and hopefully resolve that issue. And what really comes and becomes apparent is, as we were talking before, let’s go to the “I did a hard thing.” They said they had harm OCD. And as I said before, it can feel really validating to know you have your community like, “Oh, I have perinatal OCD.” So, you have your little-- you can find a group of people who have the same obsessions, and that can be really validating. It can be very, very comforting to feel like you have that community. But for those who don’t feel like they fall into a subtype, they may actually feel quite isolated and alone, like unseen. And that doubt can really make it really difficult.
And what I thought was really interesting is somebody said to me, the doubt can make you feel that it really is about the content, not the OCD. So, remember, we’re always talking about like, it’s not about the content. The content doesn’t matter. And in this case, they were saying, no, it really does feel like the content matters because if your content is within a category, well then you get that community, you get that reassurance. Not compulsive reassurance, but you get a little reassurance like, “This is OCD, you’re on the right track, keep going.”
So, I have such compassion. If you are somebody or your client is somebody who has an obsession that doesn’t fall into these categories, let’s really make sure we validate them. Let’s really make sure we slow down to understand what that is like for them.
Let’s talk about some examples of what this might look like. So, examples of what it might look like if you don’t fit into a typical OCD subtype might be: What if I picked the wrong name for my baby? Some people could go, “Oh, that’s just a normal concern. Let’s come up with a solution.” You know what I mean? That would be probably, “Let’s work at making the right choice.” And I have had clients in the past who’ve gone as far as changing their baby’s name multiple times. I’ve seen this case multiple times, trying to just figure out the solution. But you can see here, it’s not a general fear. It’s something that is repetitive and they can’t seem to get rid of that uncertainty. And even if they do change it, the uncertainty still returns and it’s very urgent. Again, we can really see that’s OCD. Clear and clean OCD. It’s got the obsession, it’s got an urgent compulsion that is repetitive, that causes distress. It doesn’t line up with their values. So typically OCD.
Some people have obsessions about the weather and whether they’ll enjoy the weather. And you might immediately think, well, again, that doesn’t sound like OCD. But again, let’s look, it doesn’t matter about the content, it matters on the process. Is this person ruminating about this a lot? Are they stuck on trying to find the correct answer or the answer that resolves their uncertainty? Is there an incredible amount of distress? Are they trying to solve this with urgency? If that is the case, we have a very clean and clear case of OCD.
I’ve had clients who’ve spent a lot of time obsessing and compulsing over the nail color that they picked or whether nail-- simple things like things they’ve chosen for their body – tattoos and so forth. And again, we could say that’s a generalized anxiety or that’s a common concern, but if it’s done repetitively and urgently and it’s causing them an extreme amount of distress, and it’s often targeted around uncertainty or anxiety or disgust, clean and clear OCD.
Some clients I’ve had have said, “What if I don’t remember something the way that it actually was? What if I can’t remember it the exact way that it was? What if I lose a part of the memory?” Now, this might show up around, let’s say the loss of a loved one. What if I don’t remember them? And we might say that is a total normal stage of grief, except this person is trying to solve this memory issue repetitively, urgently over and over again, struggling in massive amounts of distress. The uncertainty of this is really destroying them. And again, clean and clear case of meeting criteria for OCD, but they don’t seem to make these into these categories. They don’t seem to slide into a category.
I’ve had patients have obsessions about whether their partner cheats on them, and we could say, “Oh, well, they were probably--” in some cases, they have been cheated on before and we go, “That makes complete sense that they would worry about that. That’s not OCD.” But we look at the presentation and it goes far beyond generalized anxiety. It goes far beyond daily normal anxiety concerns for that situation. Again, it could become massive amounts of reassurance-seeking, rumination, avoidance, compulsions, self-criticism, self-punishment. And we can see that the way these compulsions are playing out meet criteria for OCD. And you might even say there, “Well, that’s kind of relationship OCD.” But that fits into the category. And we could argue that maybe you’re right, but I really wanted to highlight how often. Let’s say, if the partner had cheated on them and they’re having this obsession, usually, people would not put it in the category of relationship OCD because the partner had cheated on them or because a family member had cheated on their partner and they were somewhat traumatized by that event. We can sometimes miss cases because it doesn’t fall into a category.
I’ve had people and clients who’ve worried obsessively and compulsively about their thought, what if my child suffers? What if my child goes through hard times? And again, we would go, “Oh, that makes complete sense. Every parent feels that. Every parent worries about that.” But then again, it crosses a line into massive amounts of rumination, massive amounts of checking, massive amounts of reactivity. It might not even be that it’s the typical compulsions. It might be just a great deal of reactivity done because the uncertainty of this is so overwhelming.
I’ve had patients have obsessions about their taxes. What if they weren’t done correctly? They go back and they check them and then they go back and have a second opinion, and then they-- and again, we could say, “Well, isn’t that kind of like a bit of a moral obsession?” But when we ask the patient, they might say, “No, it’s not about that. It’s just about the fact that it’s uncertain.” Again, doesn’t fit into a typical subtype.
One other example I have is a lot of patients I’ve had have had the obsession, how will I know when it’s time to stop therapy? Now that’s a common rational concern. That’s actually a really good question to ask. Well, how will I know? But again, the obsession is excessive and causing them great distress. They spend a lot of time trying to figure it out. They can’t figure it out. There is no solution. The uncertainty is so overwhelming and overbearing and painful, they end up doing a lot of compulsions.
And so, there we have all of these examples, and I’m sure you probably have more of where your obsession doesn’t fit into a typical subtype but is so clearly OCD.
So, here is what I want to offer you. In this case, I’m going to give you the answer up front, and then we’re going to work through it together. The truth is, the subtypes really don’t matter. The only reason they matter is they help with treatment and they help with validation in helping people to feel not alone. But we must remember that nowhere in the criteria for OCD does it say you have to have a subtype. The only criteria you need to have is to have an obsession, a repetitive thought, feeling, sensation, urge, or image. And that obsession has to create a lot of distress in your life and can impact your functioning. Not always, but it can. And then must contain compulsions. And the compulsions are either covert or overt, meaning they’re behavioral, they’re physical, or they’re mental. They must cause a lot of distress in your life. They must take a certain amount of time. And if you meet that criteria, that’s all we really need for you to move forward with your recovery, and I want to encourage you to move forward as fast as you can. Try not to get caught up. Remember the subtypes. Just think about me being a therapist who trains staff. I have ERP School, which is our online course. That is for people who don’t have face-to-face therapy, who don’t have access to therapy, who want to learn how to structure ERP for themselves. I talk a lot about subtypes there, but only because it’s an education tool to help people get direction for their treatment. But if you don’t meet that criteria, that means nothing about whether you can recover or not. So, that’s the main point, and now we’re going to talk about how we can do this.
Now, first, before we do this, I actually want to introduce to you something that is a science-based measurement tool we use for OCD that may be very validating to you folks if you don’t have a specific subtype that you fall into that category.
Now, Jon Abramowitz and his team has created what he calls the Dimensional Obsessive-Compulsive Scale. If you Google it, it should come up. I will do my best to link it in the show notes. And this ultimately doesn’t have anything about subtypes. It really just has four categories of concerns that people with OCD have. And what I found so wonderful about that is if we throw out all the subtypes and we just look at the symptoms, we look at the process that someone with OCD goes through, you’ll probably find you fall into one of these categories. If you don’t, still don’t worry because-- but I think that this is-- I love the way that they’ve really put this together because it simplifies everything. It makes it a whole lot less confusing. So, let’s go through them together.
Number one, category 1 is concerns about germs and contamination, and they go through to explain that. If you download it, you’ll get more information about this.
Category 2 - concerns about being responsible for the harm, injury, or bad luck. And so, for that one, that includes harm OCD, it includes religious obsessions, self-harm OCD, moral obsessions. A lot of those subtypes can fall into these little categories, but I like that these are really basic.
The third is simple, unacceptable thoughts. And in these cases of people with OCD that don’t fit into the subtypes, we could easily just say, “You fall into the unacceptable thoughts category, that these thoughts are unacceptable to you. The uncertainty is unacceptable to you.”
And then the fourth category is concerns about symmetry, completeness, and the needs for things to be just right. And what I think is so helpful about that is so often these cases where they don’t fall into these more typical subtypes, I find often they do fall into somewhere around this idea of the need for things to be completed or just right or resolved. Hopefully, this Dimensional Obsessive-Compulsive Scale helps catch a net underneath all of these subtypes that can validate you, that you still fall under the category of having OCD, that you can still move forward with your treatment. You go full fledged into your ERP and move forward ultimately.
Now, that being said, we also need to look at the overlap, or maybe we should actually say the spectrum of where generalized anxiety can meet OCD. Some of these, as we said, some of these obsessions fall under maybe that’s more generalized anxiety, but we know that you could have generalized anxiety fears. But if they’re presenting with obsessions and compulsions, we’re actually going to treat it like OCD. And some people – I’ve actually really loved the OCD community – are now arguing that general anxiety and OCD are the same thing, just on a spectrum, from not so severe to very, very severe. And they’re doing that. People with generalized anxiety are doing obsessions, having obsessions, and doing compulsions. The biggest one being mental rumination and avoidance.
So, let’s round this out by talking about what to do now. So, if this is you, here is what I want you to remember. At the end of the day, and this is what I say to my clients, at the end of the day, it doesn’t matter what we call this. We could call your set of symptoms bibbidi-bobbidi-boo, and we would still use the same tools to get you effective results because what do we know? It doesn’t matter. Whatever the content is, what do we know is the problem that you’re struggling to manage the uncertainty that you’re having, that you’re having a great deal of distress and discomfort, and we need tools to be able to manage and ride that out.
So, again, if we call it this specific subtype, we call it OCD, we call it generalized anxiety, we call it bibbidi-bobbidi-boo, at the end of the day, they all require us to stop trying to suppress the thought because we know suppressing the thoughts make it worse. And then we can practice exposing ourselves to the situations where those thoughts come up without doing those compulsions. So, if you’ve taken ERP School or you’re interested in taking ERP School, we go thoroughly through what ERP is, which is exposure and response prevention. What it is, is that we expose you to the thought and fear and the obsession that you’re having. And then we practice, slowly but surely, reducing – this is called response prevention – reducing the compulsive behaviors that you do that reinforce that fear and obsession. That’s ERP. It’s actually pretty structured. We walk you through it in ERP School, but if you have an ERP therapist, they’re going to walk you through identifying your obsession, even if it doesn’t meet those categories, identifying what is your fear, and then practicing, exposing you to the life that you want to live, whether that fear shows up or not, and then practicing reducing those compulsions. The process of treatment is the same, disregarding the subtype, whether you have a subtype that you fall into or not. It is effective either way.
And so, what I’m going to encourage you to do, and I’m just going to think of this as me finishing out the podcast, but giving you some direction, is if you meet criteria for OCD, and that involves doubting your disorder-- I remember once John Hirschfeld when I was training to become an OCD therapist. He said to me, if he had his way, he would add to the criteria for OCD that you must doubt your disorder because it’s so common for people with OCD to doubt whether they have the disorder. So, here we want to do is we want to have a plan where ERP is the meat and cheese of your treatment. And what you can do then is supplement treatment with either acceptance and commitment therapy, self-compassion, mindfulness. Sometimes people use DBT. There are new supplements coming to treatment all the time, which is wonderful, but the meat and cheese is to make sure you’re doubling down on that exposure and then the reduction of those compulsions. Okay?
My message to you is you can still 100% recover from this disorder. Look at the “I did a hard thing” today and look at the review even, talking about the benefits of practicing ERP. So, that’s what I want you to focus on.
If you don’t have access to an ERP therapist, we have a course available to you. It’s $197, which is actually less than one session with any of my staff or most ERP therapists. That is about seven hours long and will walk you through this process. So, if you’re interested, head over to CBTSchool.com. The course is called ERP School and hopefully, it will give you the tools and the education you need to feel like you can get the ball going here, even if you don’t fit these typical subtypes.
Okay, that’s all I have to say about that. I hope that this has been absolutely jam-packed with helpful skills for you to learn. I hope it absolutely validated your concern if, in fact, this is a concern that you have, and it is my honor to be on this journey with you.
So, as I always say at the end of almost every episode, it is a beautiful day to do hard things. Thank you so much again for supporting me. I just adore sending out these free resources for you and hopefully filling up your cup if your cup is feeling very empty. Please also, one thing I should have said, be gentle guys. OCD and anxiety in general can be a mean beast in our minds. And one of the best antidotes to that can be kindness, gentle self-care, loving, nurturing presence. And so, I hope that’s what I am for you and I hope that is what you are for you as well.
Have a wonderful day, everybody.