During the Covid-19 pandemic, it's become not only acceptable but recommended that we wash our hands frequently, as per Centers for Disease Control (CDC) guidelines. That is, any time we're in a public place and before or after touching our face. That includes after pumping gas, opening the mailbox, touching door handles—it's endless, and it won’t end when everyone’s vaccinated and we start to recover from the pandemic.
For people with obsessive-compulsive disorder (OCD), this isn't something to laugh about—there's a vast difference between handwashing to stop the spread of a virus and handwashing that's obsessive. The Mayo Clinic defines OCD as "a pattern of unwanted thoughts and fears (obsessions) that lead you to do repetitive behaviors (compulsions). It comes down to the level of impairment and the degree to which these obsessions and compulsions interfere with daily activities and cause distress.
But OCD is not just handwashing, and it's not just a personality quirk or a way to describe someone who is “type-A”; it's a debilitating neuropsychiatric disorder. Between 2 and 3 percent of Americans will suffer from OCD at some point in their lives, and it's estimated to be the 10th leading cause of disability in the world. The good news is that OCD is treatable, but the first step is receiving an accurate diagnosis.
How Do You Know If It’s OCD, Depression, or Anxiety?
Amy Mariaskin, clinical psychologist and director of the Nashville OCD & Anxiety Treatment Center, is also the artist behind the Instagram account @OCDNashville. She takes complex mental-health concepts and turns them into comics, which has led people to recognize symptoms in themselves and seek treatment.
This is what happened to Stephen Smith, CEO of startup NOCD, during his sophomore year of college. Smith was an award-winning quarterback and had an active social life, but he started having anxious thoughts that started in one area and quickly seeped into other areas. The intrusive thoughts took over, and Smith left school and moved home to his parents' house. Within six months, he went from being a vibrant college quarterback to being homebound.
During this time, Smith received five misdiagnoses. With each misdiagnosis he received treatment, but because they weren’t for OCD, they made his symptoms worse. Marla Deibler, founder and executive director of the Center for Emotional Health, says "The data we have suggests it can take an average of 13 to 15 years to get a proper diagnosis and treatment.”
Mariaskin says many patient in her clinic had been treated before for something other than OCD, only to find their symptoms worseneing because they didn’t receive the right therapy. "Many of them find out they have OCD through engagement with media," she says, “We joke at the clinic that our biggest referrer is Google.”
After being diagnosed with OCD, the next step is finding treatment. Ash Nadkarni, Harvard Medical School instructor and director of wellness at Brigham & Women's Hospital, says, "In one study examining patients with OCD who experienced barriers to treatment, 40 percent of patients had not received treatment. Many patients received treatment outside of the gold standard for treatment and undertake ‘talk therapy,’ which lacks the same empirical support as exposure and response prevention (ERP) therapy."
What Is Exposure and Response Prevention?
ERP is the gold-standard of care for OCD because the "exposure" part of the equation subjects the patient to the thoughts, images, objects, and situations that trigger the obsession, and the "response" part is about learning ways to resist engaging in compulsive rituals. "The active ingredient with OCD treatment is exposure, so we want to come up with different ways for people to face their fears and learn to sit with the discomfort,” says Deibler.
With OCD, as with phobias, there is often a ritual or safety behavior involved that the patient thinks is helping them cope with their fear and make them feel safer, but the rituals actually reinforce the fear. Michael Ambrose, licensed clinical psychologist at My OCD Care, says, "We're not trying to habituate to the fear, but instead we're trying to build a second learning pathway. It's important to interact with things that can disconfirm your fear."
Over-predicting negative outcomes is a hallmark of OCD, and avoidant behavior reinforces the fear. When people with OCD face their fears through exposure therapy they learn that they overvalued the thought. As they progress through increasingly challenging exposures, they become more functional and their lives open up.
Ambrose stressed how important it is for people with OCD to find a specialist. "There are many conditions in the DSM-V (the Diagnostic and Statistical Manual of Mental Disorders, 5th edition) that can be treated by a generalist, but OCD is not one of them. Spending too much time talking about the obsession and trying to get to the root of it isn't helpful for someone with OCD. They need exposure to help them get comfortable with the uncertainty.”
Where Can People Find Help?
The International OCD Foundation provides an extensive list of resources, but that doesn’t mean securing treatment for OCD is easy. Many therapists trained in ERP have waiting lists, and many don’t take insurance. ERP sessions can run $300 an hour or more, depending on location. After the first two barriers of time and money, one of the biggest obstacles to battling OCD is learning how to manage between therapy appointments.
Smith saw how technology could bridge the gap in between appointments and made it his mission to create an OCD treatment platform that would allow anyone, anywhere, to access support regardless of where they live or how much money they have. NOCD accepts many insurance plans and has cash payment options for noninsured members. The NOCD app is free and available to everyone. It provides access to community support groups as well as to self-help tools.
Another option for convenient, affordable OCD treatment is TalkSpace, where a patient can opt to meet with a therapist on live video, via text, or through video or audio messaging, and they pay for the services they want. Rachel O’Neill, a licensed professional clinical counselor at TalkSpace, said, “I’ve had moments with my clients where I’m able to be part of their home or office environment through a live video session or video message, in a way that’s so much more connected than I’ve been able to be in a traditional office setting.”
Seeing a patient in their space is helpful, especially if the fear exists in that space, but what about when the fear is associated with something a person is unlikely to encounter? Many obsessive, intrusive thoughts are also taboo, immoral, or illegal, so they can be challenging or impossible to simulate. If the point of treatment is exposure, how do you get it?
Virtual Reality Can Help People With OCD
"In vivo approaches can also sometimes be prohibitively expensive, as in flight therapy for a flying phobia," said Nadkarni, "And some patients may also be more willing to try virtual reality therapy, since it could be perceived as safer, because the patient knows it can be switched off."
Mariaskin gets creative with real-life exposures for her clients, but she also uses the Oculus VR headset for some OCD subsets, such as claustrophobia. Clients wear an Oculus Go, and the therapist cues up a specific virtual environment where the walls progressively close in on them. "We control the point where the walls stop," she said, "and we can be very fine-grained in creating exposures that meet the patients where they are."
NOCD is currently testing and preparing to add a VR component to the platform. Members will have content matched to their OCD fear, and then they'll wear a headset and be immersed in 360 video meant to purposely trigger their fear. Their therapist will also wear a headset and be with them in the video. Within the safety of the virtual space—and from the privacy of their home—the patient can practice response prevention. "The stigma over mental illness is still rampant," Nadkarni said, "The more we can lower the barriers to people getting the treatment they need, the better." VR helps expose the patient to their fears in a way that would otherwise not be available to them.
“There’s space in the therapeutic landscape for different modalities,” O’Neill said. “And that helps ensure that individuals not only have access to treatment, but to treatment that works for them.” What everyone seems to agree on is that when treating OCD, the therapist needs to meet the patient where they are. For some, that meeting place is face-to-face; for others it’s through asynchronous texting, voice messaging, or video messaging. For others, the most therapeutic place to meet will be in virtual reality.