Harming and Sexual Obsessions in Children Demystified

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Dr. Kristen Mulcahy, Harming and Sexual Obesssions in Children Demystified

Harming and Sexual Obsessions in Children Demystified

Some time ago, the most adorable and articulate 8-year-old boy walked into my office and proceeded to tell me, “ So you see, I am having these crazy thoughts.  Every time I see a knife, I worry that I might, you know, do something to hurt myself.  But, that’s crazy, because I have a really happy life!!!”  As a result of these fears, this young man had started to avoid being around any type of sharp object and was compulsively seeking reassurance from his parents.

More recently, I met with parents who were concerned about their 12–year-old daughter’s constant confessing and reassuring seeking about sexual thoughts/images she was having (e.g., having sex with Dad, having sex with boys at school, even having sex with their family pets!!!).  As a result, their daughter would no longer be alone with her Dad or their cat or dog and was starting to avoid being around boys at school all together.

Although these types of worries can be quite unsettling for both children and parents (and even pediatricians and many mental health professionals who are consulted), they are relatively common and easily recognizable OCD symptoms for experienced OCD therapists.  Also, if treated appropriately, they generally diminish fairly quickly.  Unfortunately, these types of symptoms are very often treated as generalized anxiety rather than as obsessive-compulsive and generally worsen as a result.

Before we talk about what appropriate treatment entails, let’s first talk about what doesn’t work.   So, most parents (who have had any experience with these types of symptoms) have figured out that providing reassurance to their children does not work.  In fact, it generally makes the symptoms worse over time.  What kids have generally figured out is that strategies such as trying to will these unwanted thoughts or images away as well as seeking reassurance from others do not work.  These attempts, in fact, also tend to make things worse over time.

In order to explain why these seemingly intuitive strategies don’t work, we need to understand conceptually how OCD works.  So, as we know OCD is comprised of an obsessive component as well as a compulsive component.  Obsessions are thoughts, images, or even just feelings that cause anxiety and are hard to get rid of.  Compulsions are anything that one does either physically or mentally to get rid of the obsession and the anxiety associated with it.  Compulsions do work (which is why people engage in them), but only temporarily until the doubt returns, leading to more compulsive behavior and increased fears over time.  Bottom line is, compulsions don’t work long term.  Because reassurance seeking and mental reviewing are both compulsive in nature, they don’t reduce anxiety long term…but, instead, actually feed the OCD.  This generally leads to a whole lot of frustration particularly for parents who cannot understand why their rational responses just lead to more and more questions from their children.  As a result, parents end up inadvertently helping the OCD, and when this backfires, often end up angry and frustrated with their children so that they are unable to offer support when needed the most.

Another strategy, mentioned above, that also backfires is trying to will the thoughts or obsessions away.  Kids with these types of obsessions desperately try to block the thoughts out or run away from them to no avail.  Why?  Well, what happens if I tell you whatever you do, don’t think of ‘pink elephants’? Can’t do it, right?  Nobody can (well, except for a very smart 11-year-old who told me he was thinking of ‘purple rhinoceroses’). 

So, what does work?  A treatment known as Exposure and Response Prevention (ERP) is the most appropriate choice for these symptoms.  However, due to the sensitive nature of these symptoms, even experienced OCD therapists can struggle with how to appropriately engage kids in this form of treatment.  However, the reality is these symptoms are just like any other OCD symptom and need to be treated in the same way.

Exposure means actively exposing yourself to the things that provoke your anxiety. Well, for the kids discussed earlier this meant gradually allowing themselves to be in the situations that provoked their worries (being around and using sharp objects, being around Dad and the family pets, etc.).  This also meant doing some level of exposure to the thoughts themselves, by either just letting them be there (instead of trying to get rid of them) or by actively bringing them on through the use of a silly story or other creative means (e.g., making silly pictures of the child’s “gravestone” and hanging them all over).  Humor and creativity are key when working with kids with these types of symptoms. Believe it or not, you can actually have fun with this treatment. My sessions are generally filled with tons of giggling!!!

In terms of Response Prevention (which is the voluntary blocking of any compulsive behavior), this means eliminating reassurance seeking, confessing, or any mental reviewing.  Kids are encouraged to resist confessing/seeking reassurance, and parents are taught how to respond effectively (generally with some type of exposure) when kids slip up and confess or ask a question. 

So you see, an OCD symptom is an OCD symptom is an OCD symptom and should be given equal treatment with ERP regardless of its nature.  So, do not fret or fear if your child is experiencing harming and sexual obsessions…just get them into treatment and prepare to laugh!!!

 

OCD patient exercises to gain control of her OCD

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Marathon running, OCD

In my previous post, I talked about the importance of maintaining a healthy lifestyle that can help a patient’s OCD treatment plan. Kate Heaslip is a patient of mine who has been battling OCD since middle school. Recently, we chatted about how she began to exercise and run regularly to help gain control of her OCD.

View the video interview below to learn more about Kate’s struggles and triumphs to finally gaining control.

What do you do to alleviate your OCD anxiety?

Don’t Forget About the Basics

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anxiety, basics of OCD, control, Exercise, Exposure, Nutrition, OCD, Ritual, Sleep

Some very basic things often go overlooked in the treatment of OCD or other anxiety disorders. The following are important elements to assess and address as part of one’s treatment plan.

Sleep

Sleep and mood are very closely connected. Studies show that inadequate sleep tends to increase irritability and stress, making it difficult to stabilize one’s mood. As a result, OCD sufferers are likely to have more difficulty managing their symptoms if sleep deprived. Children and teens are particularly sensitive to the effects of sleep deprivation, making them more vulnerable to both physical and emotional problems.

Although sleep needs vary somewhat from person to person, the following are guidelines for sleep requirements at various ages.  School aged children need between 10-12 hours of sleep, teens require 8 ½ to 9 ½ hours, and adults need, on average, 8 hours per night.

To ensure a good night’s sleep, good sleep habits such as establishing a consistent routine around bedtime are important. It is especially important for children and teens to have a consistent bedtime that doesn’t dramatically change on the weekends. Also, making sure children and teens are not too over scheduled with activities and schoolwork will help prevent chronic sleep deprivation. For child OCD sufferers who are are perfectionists, this is a very common problem. Parents, at times, may need to set limits and make getting a good night’s rest a priority.

Nutrition

Anxiety and stress can be exacerbated or ameliorated by what you eat. In general, a diet rich in vegetable, fruits, lean protein, and whole grains is best to enhance emotional well being. Eating these foods on a consistent basis will stabilize one’s blood sugar level which, in turn, helps to stabilize one’s emotional state. Refined, highly processed foods should be avoided along with caffeine, nicotine, alcohol, and soft drinks. Making sure you are getting enough water (6-8 glasses daily) is also very important.  For some great healthy recipes, check out www.whfoods.com .

Exercise

Although it is fairly common knowledge that exercise enhances mood and diminishes anxiety, researchers are now identifying the specific biochemical changes that take place in the brain as the result of consistent exercise. They are finding that these changes in mood and anxiety can be profound and long-lasting.  In fact, one study found that the severity and frequency of OCD symptoms was reduced immediately following a session of aerobic exercise and was significantly reduced over the course of the 12-week exercise program, with gains maintained at 6-month follow-up.

Proper exercise is crucial for children and teens struggling with anxiety. Limiting video games and TV may be necessary to make sure kids have adequate time to play or engage in sports.

Making these changes may feel overwhelming for some, particularly those struggling with severe anxiety. However, it is important to remember small, gradual changes can add up to big ones over time.  Anytime, you feel the urge to do a compulsion, try refocusing your energy on making a healthy lifestyle choice. This will help promote a sense of genuine control over your life rather than the false sense of control engaging in a compulsion may give you.  Also, remember it only takes two weeks to establish a new habit. If you can drink water (in place of a soft drink) for two weeks, chances are you will no longer have an urge to drink soda.  By the way, the same is true for your exposure therapy.

What’s an “anxiety disorders specialist” Mom to do when her own daughter develops anxiety?

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Kristen Mulcahy, OCD in Children, Worry Wizard

I have three of the best children in the world and each is remarkably different.  My oldest two, 9 and 10, are easy going. Nothing phases them, much like their father.  Our third, however, is more like her Mommy… a bit of a worry wart.  When Bree was just 5 years old, she came to me in a panic and asked, “Mommy, how will I know how to drive a car?” She’s had similar concerns about going to college, marriage, and pretty much anything she can’t know with certainty. Sound familiar?

Several months ago, Bree developed an intense fear of someone throwing up on her.  Her teacher had remarked that she had been acting very differently in school.  When we questioned her about what was going on, she reluctantly told us about a girl in her class who had a bad cough and could sometimes not stop coughing.  She was terrified that this girl would lose it and throw up near or, even worse, on her.

So, at this point, the therapist in me kicked in a bit, and I spoke to Bree about the fact that kids her age can sometimes throw up unexpectedly, and that it is quite possible, even likely, someone in her class will throw up in class at some point. I pointed out that, although she would likely be able to get out of the way in time, even the worst case scenario, albeit gross, would simply mean a change of clothes and wash up…not pleasant, but manageable, right?

Bree seemed okay with this little talk, and I gave myself a pat on the back, thinking her worries of throw up were over. Little did I know, it was just the beginning.  That day, we went as a family to a magic show at our children’s school.  During the intermission, they served ice cream. Now, granted, when you combine more than 100 children with ice cream, someone is bound to throw up. However, I was not quite expecting this to happen less than a foot away from my daughter. It had to be fate as this adorable little four-year old boy walked up to Bree and literally threw up at her feet.

Again, I go into therapist mode, thinking this is great exposure. I tell my daughter how great it is that it happened and she got through it… well sort of. She was actually a sobbing, clinging mess for a while but eventually went and sat down to watch the rest of the show. Despite my trying really hard to convince her of the serendipity of this event, she wasn’t quite buying it.

The following day was her birthday pool party and I could tell she was a bit apprehensive. She made it through the swimming part of her party reasonably well, but then during the pizza and cake part, as luck would have it, disaster struck again. Yes, a little boy at her party choked a bit on his pizza and threw up a tiny bit. By this point, I was even like, “Seriously???”

Now, Bree was in full panic mode. When we got home from the party, she informed us she was not going to school the next day or, for that matter, ever.  My husband and I, at first, gently and with encouragement, explained that she would be fine and that she really had to go to school.  However, when the next morning came with a flat out refusal, the gentle encouragement turned to frustration and then full-on desperation.  I can’t remember exactly how we got her to school, but I know there were many threats made, as everything I learned in grad school went right out the window.

Despite our success at getting her to school, her behavior deteriorated quickly.  She went from being a model little first grader to an absolute nightmare.  Every time a classmate coughed, Bree ran for the hills… the bathroom, her cubby, or any place where she could possibly hide. Her poor teacher, ragged by the end of each day, was at her wits end after a week or so of this.  Similar to us, she had tried the kind and gentle approach, but was now desperate as Bree was clearly disrupting the whole class.

In trying to cope with what was happening, I realized that I had gotten myself into the same cycle as many of the parents I work with. At first, coddling and compassionate and, when this didn’t work, angry and frustrated, which would inevitably lead to guilt and despair. The whole cycling starting over again. As this was clearly not working, I realized we needed a solid plan to tackle this monster…the fear that is… not my daughter.

Trying to stay level-headed and confident (although I was not feeling that way), I met with my daughter’s teacher and one of the director’s of her school.  A bit embarrassed, I explained what I do for a living and how successful I am with other people’s kids. Thankfully, they were on board, and we put together a plan combining some exposure therapy with a great system of positive reinforcement to reward Bree for staying where she needed to be instead of running away.  We also worked on this at home, practicing not running and hiding if she heard someone cough or complain of a tummy ache. And everyday we talked about the possibility of someone throwing up in class and what she would do if this happened. She became one of my youngest beta testers for the Live OCD Free app I was about to launch, consistently practicing her challenges to fight the “Worry Wizard”.

I would like to say our system worked flawlessly, but there were many bumps in the road. I had to be as patient and trusting as I often request of the parents whose children I treat. I realized how easy it is to expect and want instant gratification. But, the learning process does take some time.

Fortunately, within four weeks or so, Bree was on her way to earning all her “suns” nearly everyday. And I am proud to say, she has now, two months later, completely graduated from the “sun program” and officially defeated the “Worry Wizard.”

I have learned more than you can imagine from this experience. It has given me a whole new understanding of the intense emotions a parent experiences when his or her child is struggling with anxiety. However, it has also made me even more trusting of the therapeutic approaches I know work so well. Even more amazing… my daughter has not only overcome her fear of throw up, but she has gained a confidence in handling all kinds of previously worrisome situations. Sleepovers and playing with dogs were both big ones that she is now perfectly comfortable with.  She now beams with pride as she tells me all the different ways she battles the “Worry Wizard” and wins!!!

Dr. Kristen Mulcahy Interviews Rick, who overcame his OCD

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Cognitive Behavior Treatment, Kristen Mulcahy, Live OCD Free

Rick talks with Dr. Mulcahy about his OCD struggles, triumphs, and how Live OCD Free has helped him regain his life.

OCD Texas Conference: “Facing Your Fears… The Basics of ERP”

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Austin, ERP, Houston, International OCD Foundation, IOCDF, Irene Tobis, Kristen Mulcahy, OCD, OCD Texas Conference

This past weekend, I had the wonderful opportunity of traveling to Houston for a conference entitled “Facing Your Fears…The Basics of ERP” sponsored by the IOCDF affiliate support group, OCD Texas.   Although OCD Texas is only in its 2^nd year as an affiliate support group, they have accomplished quite a lot, offering support and advocacy for the many OCD sufferers across Texas by hosting these types of events four times per year as well as regular support group meetings.

The goal of this event was to educate OCD sufferers about the only evidence based treatment for OCD called Exposure and Response Prevention.  Although difficult to teach all there is to know about this treatment, the presenters did an excellent job and, I think even more importantly, were able to instill a strong sense of hope among the attending OCD sufferers and their families.

The reality is this treatment really works, and I think every professional who has utilized ERP to treat OCD can attest to that.  In speaking with Dr. Irene Tobis, the President of OCD Texas and clinician from Austin, we both remarked at how crazy it is that although we have decades worth of research supporting ERP and 100’s of books touting its effectiveness, there are still so many OCD sufferers being treated with other types of approaches that are largely ineffective.  We both agreed that doing this work is a really wonderful life for a psychologist or other counseling professional…being able to offer a treatment to so many in need that makes such a huge difference in their lives.  What more could you ask for?

I suppose we need more training for professionals and even more education for those in need. I applaud OCD Texas for doing so much to get this much needed information out to their community.

Great job, guys!!!

How and Why Does ERP Work?

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Cognitive Behavior Treatment, Compusions, ERP, Exposure and Response Prevention Therapy, Habituation, Kristen Mulcahy, Obsessive Compulsive Disorder, OCD

Exposure and Response Prevention (ERP) is the only evidence-based therapy for OCD. It has been extensively researched and has been shown to significantly decrease symptoms in 70% of all cases.

Exposure is the process of gradually exposing yourself to feared situations, thoughts, and images in order to provoke anxiety. Response Prevention is the voluntary blocking of any type of compulsive behavior that would normally decrease the anxiety associated with your obsession.

ERP involves breaking the connections or associations that maintain your OCD. There are two different types of associations that trigger and (through reinforcement) maintain or exacerbate your OCD. The first type of association is created when a certain thought, situation, or image provokes fear or anxiety. When this happens repeatedly, a kind of conditioning occurs and you come to experience anxiety automatically as a result of these specific experiences. Consequently, you will likely begin to avoid these triggers whenever you can. The second type of association is made as compulsive behavior comes to be associated with feeling better and less anxious. As a result, you will tend to engage in compulsions whenever your anxiety is triggered with the expectation of decreasing it.

As you continue to avoid triggers and engage in compulsive behaviors, your OCD symptoms (both the obsessions and compulsions) will likely increase. Although your compulsions may start out being fairly effective at reducing your anxiety, over time they will become more time and energy consuming. You will need to do more and more of them just to feel better. Engaging in compulsions also causes your obsessions to generalize, meaning increasingly more thoughts, images, and situations will become anxiety provoking. More fears, in turn, will lead to more compulsive and avoidance behaviors, spiraling your OCD out of control.

The goal of ERP is to stop this cycle by breaking these associations and creating more functional ones. Repeatedly exposing yourself to your fears, or to whatever provokes your fear, will ultimately break the connection between your obsession and the increased anxiety you experience. This happens through the process of habituation. Habituation simply means you become desensitized or get used to having the obsession and/or doing whatever it is that triggers your obsession so that you no longer experience much, if any, anxiety as a result. Practicing response prevention ultimately breaks the connection between compulsive behavior and the reduction of your anxiety. Not allowing yourself to give in to any compulsions allows your anxiety to come down on its own with just the passing of time. As you gain more experience with and more confidence in this process, you will experience less anxiety and, therefore, less of an urge to engage in compulsive behavior.

Exposure and Response Prevention (ERP) Therapy for Contamination Fears

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Contamination Fears, ERP, Exposure and Response Prevention Therapy, OCD

Fear of contamination is a very common OCD symptom. The treatment for this type of fear involves exposing yourself to the things that make you feel contaminated without allowing yourself to engage in any compulsions such as washing, using hand sanitizer, changing clothes, or de-contaminating in any way.

Depending on the severity of your contamination fears, you may need to do the exposure and/or response prevention gradually. In doing exposure, you may be able to touch something “germy” directly or if this is too difficult, you may need to touch it “indirectly” by touching something like a tissue to it and then touching the tissue. In this way, you can work up to touching the contaminated item very lightly and quickly with one finger, and then work up to full contact. Similarly, washing may be cut out altogether for a while for a more aggressive approach or  it can be cut back gradually, perhaps from several washings to one…to an incomplete wash…to just hand sanitizer…to eventually no wash at all.

Since sooner or later you will need to wash, it is recommended that you “spread” the contamination. This means touching as many things as possible that you come into contact with on a regular basis. Right after touching something dirty or germy, make sure you touch your clothes, hair, face, and items in your immediate environment such as your bed, pillow, hair brush, etc.  Even try eating something with your fingers.  The more spreading you do, the better.

Accepting uncertainty is another important way to combat contamination fears.  Although it may feel like certain things are “clean” (and, therefore, can be touched) and other things are “dirty” (and cannot be touched), it is important to remember we really have no idea generally how clean or dirty things really are. Some things that are perceived as clean, if inspected under a microscope, may be full of dirt and germs. The reality is, it’s likely you come into contact with all the dirt and germs you are trying to avoid.  Therefore, doing the exposure is really nothing new. Remembering this can help you negotiate with yourself to touch things you would rather avoid and eventually free yourself from the fear.

Welcome to OCD: Real Stories, Real Help

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cognitive behavior therapy, Kristen Mulcahy, Live OCD Free, OCD

Hi everyone,

I have been treating OCD for more than 15 years.  Working with so many brave OCD sufferers over the years has been a true gift.  Sometimes, I think I learn more than I can possibly teach.  With the understanding we now have of OCD and its treatment with cognitive behavior therapy, I have seen many lives completely transformed.

Yet, despite the efforts of clinical and research professionals specializing in OCD, there are still so many people suffering needlessly.  Armed with the right information about treatment and the resources available, everyone can be helped.

This blog is intended to provide a resource for such information.  With weekly posts and/or videos, I hope to provide a place where OCD sufferers can access valuable information while learning from and inspiring each other.

I am grateful to all the brave individuals who have been willing to share their stories and I am also grateful to you for reading and participating in this blog.

Together we can help as many people as possible live OCD Free.

Best,

Kristen