We’re launching a series of op-ed pieces by clinicians and researchers who are enthusiastic about sharing what they’ve learned through years of working with patients and conducting studies.
Today’s post is written by Ryan Vidrine, MD, an Interventional Psychiatrist at TMS Health Solutions in San Francisco who specializes in OCD, BDD, anxiety, depression, and brain stimulation treatments. Ryan is a good friend of nOCD and a tireless supporter of people with OCD.
You can find Ryan here: https://www.facebook.com/ryanvmd
Doctor: “What worked?”
Patient: “Like you told me… to give a character to my OCD or BDD obsessions. It totally works!”
Doctor: “That’s awesome. So, who did you pick as the character? Darth Vader? The Joker?…It’s not me, is it?”
Patient: “I just imagine that Regina George from Mean Girls is the one behind all of my obsessions. I picture her talking to me in that super snobby, plastic way or writing down my thoughts in her burn book. She’s suuuuch a bitch — so at first I kind of want to laugh and then I start to think how ridiculous everything she is saying is, and sometimes even picture the scene in the lunchroom where everyone starts acting like animals and throwing food. It gives me just enough space to remember it is just the OCD or BDD talking, and choose to do something else more important.”
Our brain is a thought machine — its job is to churn out thought after thought. Many of these thoughts are just random things. Many others are often negatively-skewed or fear-based thoughts about “what if’s” and other possible catastrophes– often hypothetical, and often things we don’t have control over and thus cannot do anything about. But that, in many ways, is the brain’s job.
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Remember, we evolved for survival — to pay attention disproportionately to the dangerous and negative aspects of life. The problem is that these parts of the brain that sound the alarms of danger evolved prior to the development of consciousness and the ability to think, plan, hold perspectives, imagine, and worry about the future. It’s like we are using the latest iPhone X, but still running the iOS from the original iPhone. In the world we live in now, our iPhone X brains are bombarded with notifications, pop-ups, and individually targeted ads, but the old operating system we are running doesn’t have all the fancy new ways to know what is relevant, what can wait, or how to filter or turn the notifications off. And so our iPhone 1 brains are constantly buzzing and telling the rest of our mind and body that these thoughts are real and important and need attention, or else we won’t survive.
Lucky for us, our higher & newer brain parts are sort of like the Apple Genius Bar — they can employ patches, updates, training, and modifications over time to help us improve our user interface and experience… but it takes a little time, effort, and intention. If we aren’t intentional and aware of how we relate to our thoughts, we can find ourselves in a state of Cognitive Fusion, where we treat every thought we have as true, important, not up for debate, and reason enough to send our body into fight-or-flight mode…all in the name of survival.
Cognitive Fusion is a common pitfall that many of us can fall into. This is the idea that “because we think it, it must be so.” For example, have you ever found yourself saying something like, “I can’t go that party… I would die… I’m way too socially anxious.” You might even notice that as you are even describing how you CANNOT go to the party, your body is already responding as if you did go — spooning a giant heap of adrenaline right onto your plate, with all the standard sides of racing heart, sweating, skin crawling, and so on.
To make things more complicated, in OCD we often see Thought-Action Fusion— where a “bad” thought is then followed by an expectation that some sort of “bad” action or outcome is on the way. In severe cases, people believe that just having certain thoughts will directly cause specific actions to happen. I often see this in my OCD patients as intense fear that they might actually do the thought that pops into their head. One new mom’s OCD flared up just after she gave birth and, as a congratulatory gift, gave her thoughts of throwing her baby out the window. She was so scared and tortured by this that she began increasingly avoiding time alone with her child. More and more she started passing the baby off to her husband because she couldn’t see her thoughts as just thoughts — she treated them as true and capable of automatically causing action simply because she had them.
As it turns out, you CAN go the party… it’s just that this idea makes you anxious. You WILL NOT die…You WILL NOT throw your baby out the window… but your mind will certainly tell you these things, and try its best to make you feel like you might. And lastly, you ARE NOT a ball of some substance called “social anxiety.” You ARE NOT a “bad person” because your brain had a thought. You are a human being, with a brain that makes thoughts…because that’s what brains do. You are a human being with a vast array of qualities, only one of which may be that you feel anxious in some social situations. Lucky for you, you have several other resources, qualities, or skills that you can employ to “survive” situations like the above.
The general goal of Acceptance-Commitment Therapy, or ACT, is to increase psychological flexibility: the ability to contact the present moment more fully as a conscious human being, and to change, increase, or continue behaviors such that they move us closer to our values in life. Cognitive Defusion is one of the core principles of ACT– and one of the best software upgrades for your faltering operating system. Defusing from your thoughts (breaking that thought-action fusion) means using any number of strategies to create some space or distance from your thoughts, giving you the chance to remember that our brains are simply first-generation thought machines and that those thoughts are simply thoughts. Almost anything can be used as a defusion technique if it helps to break the tension, give you pause, make you laugh, or any other manner of momentarily getting you out of your own head.
As demonstrated at the start of this piece, one of my favorite defusion techniques with OCD or BDD is to have patients assign a character to their brain’s obsessions or nasty critiques. It can be anything, although in my experience, something cheeky and outrageous tends to work best, as humor is one of the best known defusion techniques. I have one patient who imagines all of his OCD thoughts coming from Kellyanne Conway and Donald Trump, telling me he finds their voices grating enough to get him out of his head– plus, it reminds him that his thoughts are “fake news.” A different patient prefers South Park characters, usually Mr. Garrison or Cartman. Another person likes to imagine that each domain of her obsessions is a different Golden Girl. She imagines the snarky, critical ones coming from Sophia, yelling at her from the confines of Shady Pines. Her sexual obsessions take the form of Blanche, her perfection obsessions are Dorothy, and her social anxiety and fear of looking stupid to others are delivered by Rose.
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Other defusion techniques include singing all of your obsessions to various tunes until they lose power, repeating or imagining your obsessions in funny or exotic accents, or even some visual techniques such as imagining your thoughts as leaves floating down a stream or words on an Etch-a-Sketch that can be shaken and erased whenever needed. If these techniques sound absurd to you, try them anyway… they still might work, and they’re likely no more absurd than many of the obsessions you are having all day long.
If these strategies don’t work, or if they just aren’t your thing, there are more subtle ways of training your brain to defuse from its thoughts over time. One trick is to pay attention to the language you use. Instead of saying “I’m going to throw my baby out of the window!” or “I am going to make a fool of myself at the party!” try to practice saying, “My brain gives me the thought that I could throw my baby out of the window” or “My brain gives me the thought that I will make a huge fool of myself.”
I’m a brain nerd so I like using the term brain, but some people prefer to say, “My mind” or “The OCD” or “The OCD part of my brain.” Whatever you choose is fine. The idea is that language is super important to our brains, and even slight changes in the language we use can have a powerful impact in how we feel and how we relate to our thoughts. These subtle changes can create a little more space and act as a reminder that our thought isn’t a fact and isn’t actually happening. It’s just a thought.
Don’t get me wrong– these techniques will not cure you. They aren’t replacements for exposure therapy or medications or support from family, but they’re one more simple tool that you can use day-to-day to get a few more minutes outside of your own head, a few more minutes connected to the world around you. And, who knows: if you have a little fun with it, you might find out that regardless of what your Regina, Kellyanne, or Sophia actually tells you, defusion really can be “sooo fetch.”
Thanks once again to Ryan Vidrine, MD, for contributing this op-ed piece. If you’re willing to share your expertise with readers on our blog, please send an email to firstname.lastname@example.org. And for more on Ryan’s work, find him on Facebook: https://www.facebook.com/ryanvmd
Lastly, if you’re a clinician or researcher looking for a new tool to make your work easier and more effective, have a look at the ways the nOCD app might help: click here.