OCD isn’t just about anxiety. Although anxiety is certainly a prominent feature of the disorder, clinicians who only attend to anxious symptoms can easily overlook some of its other core features. As a psychologist in Palm Beach, Florida, I work closely with kids, teens, and adults throughout the greater Palm Beach, Fort Lauderdale, and Miami areas on strategies for recovering from OCD. In the patients I treat, anxiety is often accompanied by significant guilt, shame, disgust, and depression. These features are not necessarily related to, or caused by, anxiety; they can be distinct processes. If you (or your psychologist) conceptualize exposure and response prevention (ERP) as only a means to habituate to anxiety but fail to consider how treatment must also address these other features, you are likely to have a suboptimal treatment response and will continue to experience significant residual symptoms. Furthermore, you might inappropriately label yourself as treatment refractory and pursue more invasive alternative procedures (e.g, psychosurgery or deep brain stimulation [DBS]) than may be necessary. Research studies suggest that these procedures can be effective, but who wants to have an unnecessary, irreversible, and expensive surgical procedure?
Not everyone needs to augment their ERP with interventions designed to address guilt, shame, disgust, and depression; however, it’s worth considering if you have had multiple frustrating experiences with treatment. There are certain classes of individuals who have to be particularly savvy when conceptualizing their OCD symptoms and selecting appropriate interventions. At greatest risk for potential clinical mismanagement are individuals with:
- Predominantly mental rituals
- “Pure O” OCD
- Violent obsessions (e.g., hit and run OCD, fear of harming others or self, fear of losing control and acting on an unwanted thought)
- Sexual obsessions (e.g., fear of being attracted to an unwanted person or object, fear of homosexuality, fear of being attracted to something socially unacceptable, fear of violent imagery)
- Scrupulosity (e.g., worry about going to hell, committing unpardonable sins)
- People who have more complex presentations of OCD that involve anger
For individuals with these forms of OCD, addressing the entire sequelae of OCD is paramount. ERP should be embedded in CBT that targets guilt, shame, disgust, depression, and other important features of the disorder. Depending on the person, exposure hierarchies should be developed to explicitly target these features (e.g., develop a guilt hierarchy or a disgust hierarchy). When possible, it is also very helpful for individuals to understand how certain neurobiological phenomena contribute to their symptoms (e.g., the neural basis for guilt). This can help a person learn to better label emotions and not confuse guilt (which is a functional emotion) with other guilt-like emotions that are experienced due to OCD-related hyperactivity in certain neural pathways.
There is nothing new or radical about this approach; in fact, it’s just good, responsible practice. Sadly, this approach is implemented far too infrequently; most psychologists just don’t know how to do it properly. The state of OCD treatment in South Florida is improving, but sadly, individuals in the West Palm Beach, Miami, and Fort Lauderdale communities still have limited options for effective treatment.
I will revisit this topic again in other posts. In the meantime, begin to consider the multifactorial nature of your symptoms. Make sure that your therapy is addressing all the areas needed to improve your quality of life. Just as you can get more skilled at managing anxiety, you also can get more skilled at managing and reducing other unwanted OCD symptoms.
Questions? Comments? Sound off below.
I agree that guilt and its affiliated emotions are often not dealt with in ERP, with the focus being so strong on anxiety. What suggestions do you have for handling guilt in ERP, and with OCD in general? I find that in ERP, the true guilt one feels is not fully experienced because it is an “instructed” action. Also, more so than with anxiety, guilt is often felt to be legitimate, so it doesn’t decrease like anxiety does by simply accepting. Maybe this is where understanding emotions and the neuroscience behind guilt is important.
My approach really depends on the situation. For example, for a person who experiences harm-related obsessions about hurting a family member or loved one, my initial approach would involve learning to differentiate between “true guilt” and “faux guilt.” I consider “true guilt” to be a very natural, adaptive emotion. It is what points the way toward change whenever one acts in a way that is inconsistent with one’s values. In this case, guilt serves as a useful error signal that one can use to adapt future behavior so that it more closely reflects personal values. “Faux guilt”, on the other hand, is a very non-functional emotion. It often reflects regret over things we cannot control or directly change. Like “true guilt,” it appears to be an error signal, but it’s impossible to use this kind of signal to modify future behavior. In the example above, a person might experience “faux guilt” due to the fact that s/he has intrusions about harming a family member. This is not guilt in a true sense, because it doesn’t serve any useful function. As much as a person might wish it, he or she cannot choose to be free from harm obsessions. When I work with individuals experiencing a lot a guilt, I work on recognizing the differences between these emotions. As you suggested, I also help the person recognize and label “faux guilt” as a neurobiological artifact related to hyperactivity of the anterior cingulate. Fortunately, this hyperactivity can be reduced through regular ERP. Although it would be a vast oversimplification to suggest that the anterior cingulate is a “faux guilt” center in a true sense, it has been implicated in studies looking at feelings of wrongness, closure, etc. As to your other point, my experience has been that it’s pretty easy to induce guilt-like feelings depending on the nature of the person’s obsessions. In some cases, it may take some creativity, though.
… ““Faux guilt”, on the other hand, is a very non-functional emotion. It often reflects regret over things we cannot control or directly change. Like “true guilt,” it appears to be an error signal, but it’s impossible to use this kind of signal to modify future behavior.” …
Hi Dr Seay, I want, if I may, to take that statement of yours above out of your given context above and use it in another for a moment… (If I may not then please just ignore me 🙂 … and Sorry!)
As a child (not so much any more now that I’m an old bat ‘cos I’ve learnt to ignore it)… as a child I suffered extensive guilt over things for which I was not personally responsible but responsible for just because I was born a “human who knew better.” I felt guilty that we humans pollute the world, kill dolphin to catch fish, mine the land and leave it befouled, dump toxic waste that kills and/or mutilates living things, create huge trashpit landfills, nevermind great big islands of plastic trash the size of Texas (thank God I didn’t know about those then!) etc. Seriously, I was daft about the stuff – I apologized to the mountains every day… because we, humans, were harming them and others by the carelessness of our existence. Even as a child, especially because I was a child, I knew there was nothing “I” could do about it. This “guilt” was real and harsh until I was well into my twenties, then I guess .. life got in the way. But even today – I remember the overpowering, mind-numbing guilt I felt about this as a child. As an adult (of 58 today) the guilt has not so much abated as become “intellectualized.” It’s there – but I don’t get my knickers in a knot about it anymore.
Background to taking your quote out of context done; back to your quote:-
Perhaps this is a kind of “guilt” that should be encouraged and “fed” in humans because if enough of us, say 80% of 7billion people, felt “a guilt that hurts” about harming the world and life on it… perhaps we’d stop doing it?
As individuals, we all want to leave our children a better life than we had. But as humans, I don’t see that we will be leaving the planet “a better place” for whatever species evolves from us?
Damn! But I hope you don’t think I’m being funny or facetious – because just writing this has brought the full force of that guilt back and I am now weeping as I write!
What about OCD and drugs? OCD and ciggeretts?
I feel I found the answers to my problem years ago and just needed to take care of my family and me, but was unable to do so as I had 3 mortgages and back taxes and my husband or no one would help me, so I got sick again and the shame of it all and anger about abuse caused my inner child to stay inside I wanted to be a good mother and nice person, but my family continues to abuse me and neglect me as they live in their 300,000 homes and my now X and family have no empathy
Hi Dr. Seay,
Do you have any reading suggestions for dealing with guilt, shame, disgust, and depression related to OCD? While much of the self-help literature mentions these associated symptoms, I’ve found it falls short in terms of addressing them specifically. Of course developing a treatment plan with a certified therapist is preferable, but sadly, not always possible.
I appreciate any information you’re able to offer!
I’m afraid that every situation is so different that it’s hard to offer general suggestions that would be readily applicable across individuals.
What I can say is that for some people, certain emotions seem to habituate less well than others (anxiety habituates best). As such, your expectations need to be calibrated properly. For guilt and shame, cognitive therapy can be an important component to include.
Disgust, in my experience, does respond well to exposure, although motivation can be an issue for some people. Depression must be understood properly in order to address it correctly. Is it driven by OCD? If so, target the OCD. Is it independent from the OCD and causing treatment-interference? If so, target the depression before the OCD (if possible). Medication may also be especially helpful in such situations.
CBT (more broadly than ERP) gets a bad rap sometimes in the literature given that some people inadvertently turn CBT strategies into mental rituals. However, there is definitely a huge place for CBT in dealing with guilt and shame.
Sorry for the rambling and belated answer. Maybe a new post should discuss these issues in relation to a specific treatment example.
Thank you for the reply. My thoughts tend to make me more upset and depressed rather than anxious now. I know that accepting the thoughts/ exposing yourself to them repeatedly without compulsions makes you habituate to the anxiety associated with them. And I know this works but what would the treatment approach be when they just make you feel guilty and depressed? I tend to use General CBT as a compulsion to the point that I’m arguing with just about every thought and emotion I’m having all day and it’s very exhausting. I also get very obsessed with how I want to feel emotionally and how I’ve felt in that certain situation in the past and why I can’t just be happy now. Which only makes things worse. Sorry for the rambling I just feel like I’ve hit a brick wall. Any advice? Thank you so much for your time.
I would also like to hear any advice on the comment directly above me. Thanks for any help you can give.
Ok. Answer above updated.
Hello Dr. Steven J. Seay,
I’ve been through outpatient treatment and inpatient twice at the OCDI Institute utilizing CBT and ERP Therapy as well as several different combinations of medications for over 25 years. I’ve gained a lot of tools and knowledge, but am still struggling greatly. I do believe the tools have helped to some degree at various times, but I do not feel that ERP has been effective in desensitizing or reducing my issues. I know it is stated the CBT/ERP with a combination of medications is the standard treatment for OCD, but I personally have not seen many have great success-to a point that I know 4 people who were with me at one of the best places for this (OCDI Institue) have now felt they needed to resort to Deep Brain Stimulation-which has had some degree of success for them. As well as many others whose lives aren’t much different now than before intense treatment.
I am curious on your thoughts in regards to OCD as a medical disease and addressing and treating it as such? After all these years of living, learning, and understanding about my disease it is my belief that my OCD has a more medical-biological basis/reasoning-a root cause that needs to be diagnosed and addressed (genetics, immunity, autoimmunity, hormones, metabolic, endocrine, neurological-addressing specific areas that my brain needs, gastrointestinal, etc) which in turn will benefit psychological approaches. Meaning I believe physical/medical issues need to be diagnosed and addressed as possible root causes. Basically, if OCD is a symptom of another underlying cause-something imbalanced in my body (possibly the root problem) and that is not being addressed or attacked than approaching or addressing psychological/mental symptoms with dozens of psychiatric medications & combinations as well as CBT/ERP will and has done nothing-“chicken or egg theory”-which happened first? For example, I recently found I have an autoimmune thyroid issue and began researching the relationship of OCD and autoimmunity and found a lot of interesting connections. But prior to this nothing like that was ever investigated or diagnosed or brought to my attention as a possible connection.
This particular article of yours interested me because I have not completely given up on the idea that ERP can be beneficial and maybe there is a different approach that could be utilized. I do not actually have a fear related to getting sick or something bad happening (so I don’t believe it’s fear-based). It’s more like a “just not right feeling” or “icky/disgust feeling” and exposing myself to dealing with the items never really accomplishes reducing/desensitizing that (it’s the same the 1,000th time I am exposed to it as the 1st time). I was taught the idea of ERP was to directly address the fear/item so that eventually your brain will acknowledge or “catch up” and desensitize you to the idea that there’s nothing to fear-thought will follow the actual action? But if I don’t actually have a fear that something bad is going to happen or I’ll get sick, what is ERP actually accomplishing-because after 4+ attempts at this approach, I’m still greatly struggling? Is the wrong approach being utilized? Is there a different particular ERP approach in these types of situations to be taken?
As you can imagine, it’s been frustrating not being able to find the help I need to feel better. I’m trying to figure out my next steps-I’ve considered Ketamine Infusion, Neurofeedback, Virtual Reality, TMS, Deep Brain Stimulation, More combinations of meds-most of which I tried including MAOI’s, etc. I would appreciate any thoughts, insights, or advice because you seem to have a great deal of knowledge and experience and it appears you also think outside the box with an understanding there’s not a “one size fits all” approach. Thank you in advance.
I did something when i was a teenager and a child that i was not proud of knowing what know now. I pretended to be a female on the web in a “relationship” with a guy for 2 years (which i now recognize as absolutely horrid), not sure why the reason was but it wasn’t for good intentions, and experimented as a child with some rather strange acts with a close friend. In passing conversation with my significant other about a transsexual person i remembered these moments and suddenly my entire view on those moments magnified a suspicion that i was not the sexuality i was my entire life and feared i was in denial or that i was repressing something because a rogue thought that made me reanalyze things that i was already confident i knew with certainty. I have no problem with gay people, but i dont want myself to be. I have always pursued women and desired those relationships and am happily engaged to the woman of my dreams but yet i still feel despair, guilt, insecure in who i am and it bothers me that even though i never pursued a man that i did those things and that some how now those things mean something different then when i did them. I am happy with my life and who i am just after this episode i feel as though i know nothing.
But now i start noticing i do not have a normal libido, i am noticing that i get anxious around men, that because i happen to see i dude walk by and i see his behind or crotch that it was intentional interest or looking and i just get more panicked even though it isnt congruent with the rest of my sexual/romantic interest history. Why oh why did i do this to myself.