Real Event OCD: What it is and How it Presents
Obsessive Compulsive Disorder can focus on just about anything. Sometimes, it focuses on germs or the fear of harming others. Sometimes, if focuses on sexuality or God. Sometimes, it focuses on health or existentialism.
In many cases, the focus is concentrated on things that haven’t happened. For instance, someone with Harm OCD may have an intrusive thought about shooting someone in the middle of a football stadium even though they don’t have access to a gun. Someone with Contamination OCD may fear that drinking directly from a carton of milk will expose them to HIV even though they live alone. Someone with Health Anxiety OCD may fear that they have a tumor even though they have no symptoms.
OCD sufferers don’t need evidence to fear the above; OCD uses the imagination as its ally.
In Real Event OCD, the disorder does this too. However, instead of manufacturing the obsessions de novo, OCD manipulates real events in an effort to cause anxiety. OCD constantly does this in other flavors as well, but Real Event OCD needs the real life component in order to feed the subset.
The Gist of OCD
OCD is a neurobiological condition marked by a repeated cycle of obsessions (which manifest as intrusive thoughts) and compulsions (which manifest as physical or mental actions aimed at reducing anxiety).
Obsessions are egodystonic – they’re counter to the sufferer’s values, morals, and true wants – and sufferers never act on them outside of performing their compulsions. For instance, someone with Relationship OCD who is afraid that they’ll kiss their coworker and cheat on their spouse never really kisses their coworker; they only fear they will. This is why the thoughts cause so much anxiety and discomfort for the sufferer. This is also why sufferers engage in their compulsions: To assure their obsessions haven’t come true or won’t come true in the future.
Unfortunately, OCD is not a disease that is easily sated. The compulsions bring relief to the sufferer but it’s always short-lived, lasting as little as seconds in some cases. OCD always comes back, demanding that those who have it perform their rituals again and again. In severe cases, these rituals grow all-consuming.
While they dominate a person’s time and dramatically interfere with the sufferer’s life, the biggest danger inside compulsions lies in the validation they offer: Each time someone performs a compulsion, they give into their obsessions and strengthen their underlying disorder. The more someone engages in compulsions, the more problematic their OCD grows.
The Foundation of Intrusive Thoughts
Intrusive thoughts are the main ingredient in the OCD dish but they’re not limited to the minds of the obsessive compulsive; intrusive thoughts pop into everyone’s head from time to time. But they differ in their frequency and intensity.
People without OCD don’t apply importance to these thoughts, which allows them to ignore them and cast them aside. People with OCD do the opposite and assign these thoughts meaning, which inadvertently invites the thoughts to appear more frequently.
Even with the above, OCD sufferers don’t entirely believe their intrusive thoughts; deep down they know they’re probably not real. But “probably” isn’t good enough for OCD; in fact, “99% sure” isn’t good enough for OCD. The disorder requires rock solid certainty. Any doubt, the slightest sliver of it, is enough to keep the OCD cycle in motion.
The Specifics of Real Event OCD
Sufferers of Real Event OCD spend a great deal of time replaying events in their minds. They may think about everything they said, they may analyze everything they did, and they may search their memory for any evidence that they offended someone, did or said something wrong, committed a crime, played a role in a tragedy, or made an incorrect choice.
They do this to reassure themselves that something bad won’t happen. For example, someone with Real Event OCD who fears that they offended their friend at a party isn’t only worried about offending their friend. They are also worried that their friend will no longer be friends with them, that their other friends will no longer be friends with them, that they’ll be socially ostracized, and so on and so on.
Common Real Event OCD Obsessions
Those with Real Event OCD may have obsessions about any event, from public speaking to interacting with the cashier at the supermarket. In general, the foundation of their obsession is the fear that they’re a bad person. Overall, some of the most common obsessions include:
- Obsessing about something insignificant that would pass over other people. Someone with Real Event OCD may obsess about whether they hurt their waiter’s feelings if they forgot to thank him for a glass of water.
- Taking guilt as proof that something bad happened. An OCD sufferer may feel guilty about something minor and reason that they feel guilty because they did something wrong.
- Fearing that they did or said something racist, sexist, or bigoted.
- Fearing that they acted inappropriately in the past.
- Fearing that they cheated on a test or on their income taxes.
- Fearing that they drove drunk.
- Fearing that their actions or words led to a complication or catastrophe. For instance, a mom who drank coffee while pregnant may fear her actions caused her child to have a speech delay.
- Fearing that they had sex without getting full consent. This type of obsession may have flared up during the Me Too movement.
- Fearing hypocrisy, inauthenticity, or being unfair.
- Fear that they committed a crime – intentionally or not – sometime in the past.
- Assuming something bad happened if they can’t remember every aspect of an event. For example, someone who imbibes in alcohol may not have a crystal-clear memory of the night in question and they may assume the worst as a result.
- Needing to know right away that they didn’t do anything “bad” or “wrong”. OCD sufferers typically experience a sense of urgency and need to find answers as soon as possible.
- Magnifying the importance of their actions. While many people don’t want to be offensive or make the wrong decisions, OCD sufferers go well beyond this and magnify the disaster potential of any perceived slight or shortcoming. For example, they may believe that something they said two decades ago to a classmate was mean and bullying and continues to be hurtful when, in reality, their classmate might not even remember the incident.
In many ways, those with Real Event OCD don’t allow themselves to be human, beating themselves up for any imperfection (or beating themselves up when no imperfection exists). However, they don’t apply this to other people. They allow others to be flawed; they just don’t give themselves the same compassion.
Common Real Event OCD Compulsions
To manage their anxiety, the sufferer engages in a variety of compulsions.
In Real Event OCD, these include:
- “Mentally reviewing” past behaviors to look for proof they did something bad, inappropriate, or offensive.
- Believing they need to be punished for their actions.
- Asking for reassurance from friends and family members. For instance, if the sufferer attended a party the night before, they may ask their friends if they did anything bad or said anything nasty.
- Retracing their steps so they can remember exactly what happened.
- Apologizing unnecessarily or for things from long ago.
- Confessing for their imaginary sins.
- Avoiding social functions or other types of gatherings in fear that they will offend someone.
- Engaging in self-discovery to assure themselves that they’re a good person.
What Causes Real Event OCD?
Regardless of the type of OCD, there is no one cause. It typically occurs as the result of several intermixing factors, including:
- Genes: About a quarter of those with OCD have an immediate family member afflicted as well.
- Brain abnormalities: Studies suggest that those with OCD have a hyperactive amygdala, compromised communication in the frontal and deeper areas of the brain, and differing volumes of grey area (when compared to the normal population).
- Irregularities of certain neurotransmitters: OCD sufferers often have lower-than-normal levels of serotonin and dopamine and higher-than-normal levels of glutamate.
- Mutations in the serotonin transporter gene (hSERT), which compromises how the body responds to serotonin.
Learned behavior (i.e., compulsions) plays a role in the severity of the condition. While it doesn’t cause OCD in technical terms, it solidifies it as a full-on disorder. Without the compulsions, OCD is unable to latch on the way it does; it requires rituals (mental or physical) to keep its torment going.
How Dysfunctional Beliefs Play a Role
According to the Obsessive Compulsive Cognitions Working Group, there are six types of dysfunctional beliefs that define OCD. These include:
Hyper-responsibility: OCD sufferers tend to believe and/or fear that they’re responsible for areas outside of their control. This helps perpetuate the underlying guilt that drives the illness.
In Real Event OCD, the sufferer may feel as though they are responsible for someone else’s actions. For instance, if they know someone who committed suicide, they may fear that they once said something to this person that played a role in their decision to end their own life.
A Need to Control Thoughts: The desire to control thoughts is not limited to OCD; neither is the inability to administer this control. But those with OCD may attempt to control their thoughts because those thoughts create so much terror.
In Real Event OCD, a sufferer may experience an intrusive thought that they said something racist during a dinner the previous evening. They may adopt thought-stopping activities, including putting a rubber band around their wrist and snapping it whenever the thought enters their mind. But the more they attempt to inflict control, the more powerful their OCD becomes.
Magical Thinking: Magical thinking is also called “thought-action fusion” and is the idea that something can happen simply by thinking about it.
In Real Event OCD, someone may fear that thinking something bad is the same as saying it, yelling it, or engaging in an action that encourages it. They may perform compulsions around their guilt and shame as a result.
Overestimation of Threats: People with OCD tend to both overestimate legitimate threats and manufacturer nonexistent ones.
In Real Event OCD, a sufferer may have gotten creative with their tax returns a few years ago. Even if they wrote off something that wasn’t a clear business-related expense, the threat of an audit is minimal (and getting creative with taxes is why many CPAs are employed). But the OCD sufferer will overestimate the consequences of their actions, perhaps even fearing that they’ll end up in jail because they claimed a home office and then occasionally used that space for non-business activity.
The Need to be Perfect: Perfectionism is quite common in the general population with about a third of the public affected. In OCD sufferers, nearly 100% are influenced be perfectionism to some degree.
In Real Event OCD, the sufferer has no room for their imperfections, believing they need to be perfect in every decision they make and perfect in every interaction with others.
Intolerance of Uncertainty: The inability to tolerate uncertainty is really what OCD is all about. Sufferers have an underlying desire to be 100% sure, 100% of the time.
In Real Event OCD, a sufferer may know, deep down, that they didn’t do anything bad, say anything bad, or hurt anyone’s feelings. But they need to know for sure, which is why they seek reassurance from others, confess unnecessarily, and apologize when no apology is warranted.
Factors that Influence OCD
OCD is found across racial lines, socioeconomic status, gender, and nationality. While it affects people of all ages, it usually first appears during early adolescence (8-12 years) or late adolescence/early young adulthood (19 or 20). It’s rare for OCD to start in mid-life or later.
OCD may be influenced by several factors, including:
- OCD, OCD-related disorders, or autism in the family.
- Transitions, stress, trauma, or brain injuries – While these are unlikely to cause OCD outright, they can trigger a latent disorder or cause a relapse.
- Strep – Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) can cause OCD-like symptoms to appear out of the blue in otherwise unafflicted kids or it can worsen symptoms in kids whose OCD was previously under control.
- Societal movements – Like much of the above, these don’t cause OCD but they may influence obsessions, particularly in Real Event OCD. For example, someone who fears saying something racist may fear it more during heightened calls for social justice.
There are several factors that don’t influence OCD, including:
- Toilet training: Freud hypothesized that toilet training, especially when done in a domineering style, causes OCD but this theory is no longer accepted
- Parenting (outside of genetics)
- Personal preference
- “Enjoyment” of compulsions: People with OCD don’t engage in compulsions because they enjoy them but instead to modulate their anxiety
Treatment for Real Event OCD
No matter the type of OCD, the disorder is generally addressed in a similar manner starting with the most important focus of CBT with ERP therapy. Medication may be used supplementally but it doesn’t prove beneficial in everyone.
Overall, treatment includes:
Cognitive Behavioral Therapy (CBT ) with Exposure and Response Prevention (ERP): If OCD treatment does not involve CBT with ERP, consider it a red-flag; across the board, this is believed to be the most effective type of treatment.
During ERP exercises, sufferers are asked to expose themselves to their intrusive thought (either intentionally or as part of everyday life) and then resist the urge to perform the anxiety-reducing compulsions.
In Real Event OCD, for instance, a sufferer may be asked to expose themselves to the idea that they said something hurtful to the mailman as he dropped off a package. They will then be instructed to refrain from apologizing to the mailman, from seeking reassurance from others who may have been there, or from engaging in any other type of checking behavior (such as waving at the mailman and seeing if he waves back).
The point of ERP therapy is to teach the sufferer not to respond to their intrusive thoughts. This is the key to controlling OCD: Give it attention and it’ll want more but ignore it, and it’ll go away.
When put to pen and paper, ERPs sound much easier than they are. They cause the sufferer loads of discomfort and anxiety, which is why they’re so hard to perform. Most therapists start their patients out on lower level ERPs before moving into the more bothersome thoughts. This allows sufferers to gain confidence and see firsthand that ERP works.
Even then, stopping and failing is common. But as long as the sufferer keeps trying, they’re building resistance to the tales OCD spins.
Part of ERP also involves the idea of accepting uncertainty (as previously noted, this is at the root of the condition). Sufferers learn through practice that they can never be 100% certain about anything and that they can be okay with this.
Medication: Approximately 70% of OCD sufferers respond in some way to medication. Yet whether or not a response is generated, there is no magic pill that makes OCD go away in the manner antibiotics cure strep or aspirin relieves a headache. Rather, the medication is used to dull the thoughts enough so that ERPs can be completed successfully.
The reason not all sufferers respond to medication is because everyone has different genetics. OCD meds, similar to medication on the whole, are designed to work in people with normal drug metabolism. Anyone who has genetics that metabolize drugs too quickly or too slowly may either experience a lack of response to those drugs or side effects that are so severe they make the medication contraindicated.
While people can’t change their drug metabolism, they can learn where they lie on the spectrum, saving them a great deal of trial and error. This genetic test must be ordered by a doctor but it’s often covered by insurance.
Depending on genes, there are several drugs most often prescribed, starting with SSRIs (or Serotonin Specific Reuptake Inhibitors). These include:
SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors) are commonly used as well and include:
Anafranil (Clomipramine) is prescribed too. This is not an SSRI or an SNRI but a tricyclic antidepressant. It’s believed to be among the most effective drugs for intrusive thoughts but it can come with unwanted side effects, including weight gain.
In instances where the above drugs are ineffective or contraindicated due to preexisting health conditions, doctors may turn to off-label prescriptions. These drugs are approved by the FDA but they’re not approved specifically for OCD (though it’s likely this will change).
Some of the most common off-label meds include:
Supplements may be used too but anyone considering this should speak to their doctor first. Some supplements, especially those that increase serotonin like St. John’s Wort, can interact with prescription drugs and cause serious complications.
ACT Therapy: Acceptance and Commitment Therapy (ACT) is making a name for itself in OCD circles and is increasingly used for various types of anxiety. The point of ACT is to teach the OCD sufferer to accept the intrusive thoughts instead of reacting to them, responding to them, or giving them the proverbial time of day. One of the keys to ACT is to disassociate from the thoughts and view them as a separate entity. Sufferers may be asked to get creative as a way to help this process, imagining their thoughts on billboards, on movie screens, or on pages of magazines.
For example, in Real Event OCD, the sufferer may fear that the argument they got into with their mother-in-law caused her heart attack (which, according to OCD, will result in her hating them and lead to the sufferer’s marriage ultimately dissolving). Instead of engaging in a compulsion and asking for reassurance or looking on the internet for causes of heart disease, the sufferer is instructed to say, “I’m having an OCD thought that I caused my mother-in-law’s heart attack” or “My OCD is telling me that I caused my mother-in-law’s heart attack.” This is more effective, more removed, and easier to accept than, “I caused my mother-in-law’s heart attack.”
The intention of ACT is to separate fiction (the lies OCD tells) from reality through acceptance and self-compassion.
Lifestyle: OCD sufferers shouldn’t attempt to control their disorder without professional help. But as a form of supplemental treatment, lifestyle changes can help manage symptoms.
- Eating more fruits, vegetables, and whole grains and less saturated fat, sugar, and red meat
- Exercising every day
- Engaging in a relaxation routine, such as yoga, mindfulness, or meditation
- Quitting or at least limiting tobacco, coffee, and alcohol
- Going to therapy weekly and practicing ERPs outside of session
- Finding support groups with OCD sufferers who have similar OCD subtypes
- Maintaining social relationships and participating in activities in which they find joy
- Getting adequate sleep and practicing proper sleep hygiene
- Going to bed at a reasonable hour (there is new evidence that suggests obsessive thoughts are harder to control in people who go to bed late)
TMS: In severe cases where more traditional forms of treatment fail, Transcranial Magnetic Stimulation (TMS) may be used to reduce OCD symptoms. This procedure is more-oft prescribed for depression, but it shows promise for OCD.
TMS is non-invasive and relies on the magnetic field to regulate the deep areas in the brain. It’s not brain surgery, but it is an intensive type of treatment and it requires a commitment to daily appointments for 4-6 weeks followed by maintenance sessions.
Finding an OCD Therapist
As many with OCD know, it’s not merely laypeople who misunderstand OCD; clinicians misunderstand it just the same. Because of such a widespread misconception of what it is and how to treat it, OCD sufferers must choose their therapists very carefully.
When looking for help, search for those who have specific training in OCD and who have earned certification in programs dedicated to it. The International OCD Foundation offers a directory where sufferers can search for qualified practitioners based on city or zip code.