OCD is associated with guilt, shame, disgust, anxiety and depression.
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
- Harm 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)
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.
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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.