Professor Paul Salkovskis: Webchat

Professor Paul Salkovskis, OCD-UK patron and OCD expert took time out from a very busy schedule to help OCD-UK and our website users by taking part in a live webchat for you.

So on Thursday 26th February 2009, Paul and Ashley linked through modern technology got typing on your behalf!

All the questions were submitted by visitors to the website, which Paul using his best speed typing attempted to respond to for you.

OCD-UK would offer our extreme gratitude to Professor Salkovskis for staying behind after an already busy working day to complete the webchat. And many thanks for your participation, the response was tremendous with some great, insightful questions.

Quick links to questions: Q1, Q2, Q3, Q4, Q5, Q6, Q7, Q8, Q9, Q10, Q11, Q12, Q13, Q14, Q15, Q16, Q17

 

Live Webchat Questions

Question from Lottie

Hello and thank you for taking the time to answer all our questions!

I was just wondering if you had a favourite analogy that you use to describe OCD? Thank you, Lottie.

Paul's Reply:
Yes. OCD is a Bully!

Think about what bullies do, what they want and so on. then think about how best to defeat a bully. is is best done by giving in, giving the bully all it wants? then think.....if you decide to stand up to a bully, how do you feel? anxious? If you persist in standing up to it, is it worth it IN THE LONG TERM?

Paul.

 

 

Question from Debbie

I'm concerned about the lack of attention given to physical compulsions involving the body. These are never mentioned in books on OCD. I'm talking about things like difficulty in swallowing, tightening or controlling certain muscles in the body, etc. Why is this form of OCD so often over-looked?

And could you possibly give a brief explanation of how these types of OCD would be treated?

Thank you for your time in reading my question. And thank you both Paul and Ashley for taking the time and trouble to arrange this web chat.

Best Wishes, Debbie.

Paul's Reply:
Dear Debbie, You're welcome!

These are mentioned from time to time, but are relatively rarer. As with other types of OCD, it depends on the meaning that the bodily function has (and, more particularly, the meaning that NOT doing it has). swallowing can be a checking thing (is my throat going to block?) or a neutralising response (if I don't swallow, then something terrible will happen).

Treatment would involve what CBT does usually; therapist and sufferer work together to make sense of the problem (assessment)
once sense has been made, this is translated into a shared understanding.

Goals are set; short, medium and long term; therapy is not just about taking bad stuff away, but also about reclaiming your life
therapist and sufferer consider how this different, less frightening understanding fits with what the person already knows, including the gathering of "evidence" beliefs are challenged using cognitive techniques therapist and sufferer think about how they can test the shared understanding out, and devise "behavioural experiments"; these are often, but not always, exposure and response prevention based. Treatment is generalised to where it is most needed (where the problem is most severe) relapse prevention is considered.

Paul.

Note from Ashley:
Paul talks more about what the therapist and sufferer should be doing in treatment in the 2008 OCD-UK Conference audio recordings which will be available from next week.

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Question from Anonymous

Dear Paul,

Please could you tell me what is the best way to stop ruminating?

I often write down my thoughts and worries on my phone to get them out of my head, is this a good idea or is it just another compulsion? When I am having awful thoughts and doubts it feels like I've got TEN worlds upon my shoulders, it's such a horrendous, awful feeling so I was wondering if it's a good ,when I am feeling that way, for me to tell my Mum exactly what the thoughts are to get them off my chest so I don't feel so alone or is this just another compulsion?

When I am absolutely DESPERATE for reassurance should my partner give in and check for me? Occasionally when he does check for me it then allows me to enjoy the rest of the evening but when he refuses to check something which is causing me extreme worry, I suffer so much and the pain becomes unbearable which then causes me to ruminate to try to reassure myself.

From Anonymous.

Paul's Reply:
Hmm, how to put a lifetime's work in a brief answer!!!
In a nutshell, ruminating cannot be stopped, it can only be ignored. thinking things through is not a way of stopping obsessional worries; its like digging to get out of a hole!!
the ruminator has three types of thoughts
the intrusion (e.g.. maybe I want to kill my husband)
the meaning (e.g. having this thought means i want to do it)
the neutralising thought (e.g. I love him very much, I really don't want to do it, I must persuade myself of this)

Stopping it is to realise that it is normal to worry, and to allow the thought to pass through your mind....to treat it as mental junk not worth anything its just OCD, does not need house room that's tough to do, and where a therapist often come in handy.

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Question from Aimsley

I was wondering, will the OCD EVER go away completely or will there still be aspects of it throughout the rest of my life? I have contamination OCD and i just don't see it ever going away completely. Is there anything I can do to make it go away completely?

Any advice will be much helpful. Thank-you. Aimsley_87

Paul's Reply:
For many people, treatment helps you to get rid of OCD completely for short times, longer times and for some lucky people forever.
contamination fear is one I would usually hope can go away completely, because it can be confronted, confronted and confronted. with a bit of Cognitive work as well, I would hope that you could be free. its hard work, and tough....but possible.

That doesn't mean that if you don't get rid of it it was because you did not work hard enough; the trick is knowing where to direct your efforts. sometimes it is important to have the right therapist to help you know how to do that.

Its like learning any skill; for some it comes easily, for others they need a good coach and lots of practice. Never never give up hope.
Take on beating OCD as a full time occupation. treat it with contempt. think of the bully analogy; keep on going at it until it gives up!!!

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Question from Katy

Hi, I am an OCD sufferer, I have been suffering from OCD for 9 years. My OCD was triggered in my first pregnancy, I had problems with checking and repeating phrases to keep my baby 'safe' and mild contamination issues. In my second pregnancy (5 years later) I began to suffer with severe contamination OCD which began to focus on HIV, my obsessions and compulsions would last my entire day and the only rest from it I had was when I was sleeping. Almost four years on I have battled with OCD, with the help of medication that I started in August 2008 (citalopram 40mg and propranolol 80mg) I have got to a point where I can control alot of my OCD and I can now control the worry of what I call every day germs (coughs, colds, sickness bugs and so on).

However I still struggle with HIV worries, I know I should be able to apply the same rules that I have for my other OCD worry's but this fear seems to be the strongest and most real. I have had some CBT sessions, which possibly did help me. However there were never any plans in place to help with my HIV fear. What I ask is the right way to tackle this, I am terrified of red stains, I wont touch people for fear that they may have HIV, doctors surgery's, chemists, public toilets and so on are places I do my upmost to avoid. I just need some guidance, something to get me on my way to crack this fear also. Many Thanks Katy

Paul's Reply:
If CBT did not help you with hiv fears, then that was a gap. Get more!!! Perhaps a different therapist? Find a red stain, touch it, eat a sandwich. Your problem is not HIV, its fear of hiv as part of OCD. If you react to what's happening to you as if its hiv, then your fear will stay. If you deal with your fear (the bully....see first answer) your fears will fade and you will laugh in its face. Don't give it house room. Get support in confronting it, when you confront it, don't see-saw (that is....touch a red stain, then think oh oh i'm contaminated, better make sure I contain it.... watch where it goes, then wash anything I touch....no good!! Lose track of it. its OCD, not HIV. OCD damages your life more than HIV every could.

Paul.

Note from Ashley:
Paul and Dr Fiona Challacombe are conducting some research in OCD for new mums. Read more by clicking here.

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Question from Kathryn

Hi Paul,

I wonder if you would be kind enough to give me some advice re. treatment. I have had anxiety and OCD for ten years, I am 31 now. I waited a year for CBT which I have been having for the past 9 months. They now want to stop my treatment but I feel I am no better. I suffer with fearing I'll cause harm when out and this has kept me virtually housebound for the last few years. I have found the exposure so hard because of the severe anxiety it causes I may succeed to go out a few times but then I will become so anxious that I will not feel able to go out again.

I have tried SSRI's and am now on clomipramine at the highest dose. I do not feel they should stop seeing me now as I'm not any better and also my boyfriend has cancer and is going through chemotherapy so it is a very stressful time and I feel I need support.

I have looked at the guidelines from NICE and they say if treatment hasn't worked then "the patient should be referred to a multidisciplinary team with a specific expertise in the treatment of OCD/BDD for assessment and further treatment planning" rather than discharged.

Do you think they are right in discharging me or would I qualify for further help? How would I go about trying to get more treatment at the Centre for Anxiety Disorders and Trauma?

Thanks for reading. Best wishes Kathryn

Paul's Reply:
Dear Kathryn,
Hmm, of course I only have the details you include here. My tentative thoughts are that if the treatment you are having is not helping, you need something else. Now you can see why I'm a professor ;-)

There's CBT and "CBT"; sometimes people offer complete rubbish saying that its CBT. I sometimes give a talk (did it at the OCD-UK conference in 08) on vetting your therapist. Its on (or about to be on???) the OCD-UK website, it suggests questions you should ask your therapist, how to work with them and so on. a key question is the polite version of "do you know what you are doing??" Are you trained in OCD treatment? and so on.

Specialist help sounds like a good idea.... Regional??? ask for BABCP accredited. National? our own unit, Mark Freeston's bunch in Newcastle Upon Tyne, others. For some NCAG (see OCD-UK website....ash...link???) which is our own unit or the inpatient CBT unit. advantage of that is that your local trust doesn't have to authorise it (It's already paid for by Dept of Health).

I cant comment on them discharging you per se, but it sounds a bit harsh to discharge without further help when you have not been helped and are struggling with some major problems too.

Paul.

Note from Ashley:
Paul's talk 'Getting the most for your therapist' was indeed at the 2008 OCD-UK Conference, audio recordings will be available from next week. The NCAG link Paul mentions is the National Commissioning Group of the Department of Health. Link to that information can be found on our website here.

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Question from Emma

Dear Paul,

I am a member of OCD UK. I was diagnosed with OCD when I was 22, but we think I've had it since I was about 6 or 7. I'm 26 now.

I had a nervous breakdown in the last year of my BA Degree and this is when I saw a psychologist and psychiatrist for the first time and was diagnosed with OCD, depression and severe social anxiety. I'd never heard of OCD until this point.

I have had 2 courses of CBT which helped me hugely and I can now recognise an OCD thought and challenge it. My compulsions are greatly reduced and I would say I am in recovery with intrusive thoughts/worries (of my mum/husband dying horrific deaths) that I mostly over-come and can get back into proportion or rationalise using 'thought records'. I am on 150mg of Anafranil and 25mg Seroquel. I have much longer periods of clarity now and I feel like my mind is attached to my body again, but I still have episodes of shattering low mood, feelings of unreality and sheer panic at having to face the world.

Since my breakdown I have continued with my education working from home. I have now been working from home for 4 years, but can go out now (although this is very frightening) by myself and use buses and trains. I've got my first driving lesson booked for this Sunday :) I've been given a place on a teaching course starting in September '09 and must work on campus 9-5 mon-fri. I am frightened and excited to be making this transition into 'the real world' and wondered if you can give me any advice for coping skills, or where I might find information on 'recovery & re-entering the world'? I feel that now I am so much better there isn't much support for the last hurdle, of re-integrating myself into society/work/the outside.

I hope that once I am outside, working amongst people and in a healthy routine I will be a lot better as I won't be sat here in my flat, with my books, looking out the window and catastrophising/dwelling. I am very tired all the time at the moment and feel that this is partially due to my low mood and that if I was more active I would have more energy.

Is there a book or course for the re-integration of OCD survivors?

I would be incredibly grateful for a reply. I have been working hard to help myself, using the relaxation techniques and thought-challenging techniques taught in CBT. I also go to an all woman's Gym with my mum which has helped me get used to being around people as well as using the machines that countless hot and sweaty people have used!

My main fears of being back among people are that I will suddenly have an episode of derealisation in front of them and cry or go crazy. I also have an embarrassing fear. When I am nervous I get terrible wind and I'm terrified of breaking wind in public. I keep fantasising that I will do this in front of a class and will be totally humiliated, have to quit my job, leave the town, will have another breakdown... etc.

I hope this email isn't too long.

Thank you so much for all the wonderful work you and OCD UK carry out. You are a real lifeline. Best wishes Emma.

Paul's Reply:
Sounds to me like you just identified a job for OCD-UK and or myself!! "reclaiming your life". Its really really key. Why bother getting your life back from ocd if you are not going to do something with it?

Of course it should be what you want to do...climb everest or watch lots of daytime TV. I really enjoyed the movie "the bucket list"....but we should all work towards what we want to do everyday without the threat of death!!

You sound like you have done a brilliant job of reclaiming your life.
coping skills....work out (yourself, with help whatever) what your fears are. You say "I am frightened and excited to be making this transition into 'the real world" frightened of what? What is the worst thing that can happen? how bad is that? will you survive it? is it best to avoid it or go for it? Coping means doing it anyway.

I recall a friend looking utterly frazzled as I passed him on the stairs and I said "not coping dennis?" and he replied "I'm coping, but just not enjoying it". You are at the stage when you will cope, I think, but you might not enjoy it AT FIRST. However, once you are on your course, you will begin to. given how much you have progressed, thing.....did I enjoy the process? no. Am I enjoying the results? yes. so.... more results needed. support.....what about OCD-UK? They are pretty good. Brag on the bulletin board. I cheer every now and then when I see what people achieve be one of the people I and others cheer!!

Paul.

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Question from Elke

Hello Paul,

I've found that Cognitive Behaviour Therapy didn't work for my Pure O OCD, as they are so random, pop in and out so quickly, are different all the time and caused such a high level of anxiety. Can you suggest any other form of therapy or ways forward which don't involve medication?

Thank you

Paul's Reply:
I'm a bit surprised.....random and popping in and out quickly shouldn't be an obstacle. Your therapist should have helped you major on the MEANING of the thoughts. My suspicion is that you had NVGCBT (not very good cbt).

there is nothing else that works consistently!! but if it is right, CBT works consistently.

Paul.

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Question from David

Hello I was wondering if Professor Salkovskis could give some tips on best coping with the moment when a sufferer gets over their OCD and how family can readjust to accommodate the sufferers newfound freedom. My wife is currently questioning everything about out relationship and I'm very concerned about the stability of our marriage.

Regards David

Paul's Reply:
David, not sure if you mean from the point of view of the sufferer or their family!!

It's not an awful problem to have! the answer is, of course, to communicate. lots. work out shared and non-shared goals. do things together. date; take her to the movies, dinner, go for walks, whatever.

Go skiing, go to the swimming pool......live life. the sufferer usually wants to repay the support they have had, the family don't require that, so find ways of enjoying the freedom to have a better relationship. I know I sound like the little book of calm there, but......

Paul.

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Question from Jenni

I suffer from mostly compulsive OCD. I am obsessed with symmetry, mainly to do with my feet when I'm walking. There is no real reason for it, unlike hand washing/checking - and is completely unrelated to the few obsessions I have.

Can I overcome this even without a reason for it, and will it be more difficult? Thanks, Jenni

Paul's Reply:
Hard to say. There is always a reason, sometimes hard to find.
be obsessively assymetical for a while. see what comes up. OCD is a bully (see the first post) so do the opposite of what it wants you to do. v sign to OCD.....

If it bites back when you do this, then that will probably put you in touch with the reason. if it doesn't bite back, devote yourself to doing ocd stuff for three months... If you succeed then you will get better. i'd be optimistic on the little info you have given...

Paul.

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Question from Ashley

Dear Paul,

I had a member call me this afternoon asking if the fact she has had OCD for many, many years, now engrained without access to treatment because of bad GP advice 20 years ago means that CBT may not work for her now at her age (in her 60s).

Ashley (for an OCD-UK member).

Paul's Reply:
It's really really surprising but it does not mean that she will not benefit. 20 years without treatment is very sadly not unusual. Treatment response is not related to how long you have had the problem. Having the problem for a long time means that the damage to others areas of life goes up... OCD, nasty little thing that it is, is like a cuckoo in the nest. it throws everything else out so that it can get the goodness out of your life all for yourself.

What that means is that you need to knock OCD on the head AS SOON AS POSSIBLE then get on with the tricky business of reclaiming your life. The longer you leave it the harder that can be, as everyone who has suffered knows.

Tell her to go for it so that the next twenty years aren't like the last ones.

 

 

Final Note from Paul

Paul asked us to pass on his thanks to you all for the questions and that he really enjoyed being able to respond to you all. We hope you found the responses helpful.

That's it for now, we hope to repeat the webchat again later in the year.

 

 

The following questions were submitted just after we closed our webchat for the evening. Paul kindly returned a few days later to respond to these subsequent questions.

Question from Robb

Thanks for answering our questions.

I have had OCD since 13-14 yrs old.
Medication didn't work for me, but CBT has helped me a great deal especially with stopping myself from associating my obsessions with events around me.

I still have trouble though with religious thoughts, which I did speak to my therapist about although the therapist didn't seem to know what to tell me.
The problem is I have a very hard time separating what is probably OCD and what I can question about my beliefs.

Do you have any advice on this subject regarding religion.

Thanks.
Rob

Paul's Reply:
Again, tough without detail. I don't even know which religion!!
If you have religious values, then therapy needs to work within those values. Clearly being religious is not an obsessional symptom, but preoccupation with the details of religion can be. In which case its the preoccupation which needs dealing with.

 

 

Question from Roami

Dear Paul,

What should we do when our obsessions/fears are an inevitability? Like death?

Roami xxx

Paul's Reply:
It really depends on how the OCD works for the particular person. In general, the treatment of OCD involves helping the person make sense of the way their fear works.

In worries for example about death, death is not the problem, but the way the person finds themselves preoccupied by it. So treatment is about helping the person deal with their pre-occupation.

 

 

Question from Roami

Dear Paul,

If you feel this question it too personal please don't answer it, but I wonder do you have OCD yourself and is this one of the
reasons why you are particularly interested in this area? Some of your comments at the conference, e.g. those relating to having
thoughts about harming your children suggest that you might? If so, how has this impacted on your life and how do you cope with the
thoughts?

Thank you.

Roami xxx

Paul's Reply:
I don't have OCD myself except in so far as the basic elements are there in everyone. Everyone has unacceptable thoughts etc, and I was illustrating that. People don't often discuss them because they are are regarded as unacceptable.

In my case, the thoughts and my reaction to them don't interfere with my life. Why does it interest me so much? Hard to say, but at least in part because I very much like working with people with OCD.

 

 

Question from Anonymous

One question I'd like to ask Paul is: From my own experience of having received "traditional" CBT (one which looks for evidence to
disprove irrational negative thoughts) for Generalized Anxiety Disorder, I find my mind uses this automatically to try and deal with
my OCD worries. As I already know my OCD thoughts are irrational and that this type of CBT is in contrast to the exposure and
response type CBT for OCD, are there any common techniques that can help people who suffer different kinds of anxiety?

Paul's Reply:
Hmm. Sometimes, "traditional" CBT of this kind becomes a kind of "mental arguing" which can be thought of as self-reassurance and neutralising.

All CBT should seek to help you identify the beliefs which underpin your fears, and work on these. "disputation" is more head than heart, and its shifting what you believe in your heart that matters, and then being able to act the alternative, less threatening explanation.

 

 

Question from Catherine

Basically I get a bit confused about what is the dividing line between 'getting on with the moment' and distraction. I talked with
Blake about distraction eg when trying to resist compulsions/doing REP and my understanding is that it's a 'bad' thing to do. What
he said was to just try and get on with whatever is going on in your life at that time.

Say I am doing exposure work with my therapist now and we come back from the shops and I feel very contaminated. I am working on not washing when we come in and actually going around the house touching things such as my towels, bedding etc. Then we sit down and talk for quite a while. I would argue this talking is distracting me from thinking about my contamination as I get absorbed in it.

As soon as my therapist goes I try to do more and more things in an effort not to wash or think about it. Is this distraction? As soon as I eventually stop 'doing' I am compelled to wash.

I feel I'm getting into this pattern and am concerned about it.

Cartherine

Paul's Reply:
This can be difficult. My view is that distraction is unhelpful when you have intense fears about what will happen if you don't do it.

Situation a: I know that my OCD makes me feel contaminated. I have confronted my contamination, and it will take a while to get used to it. I like football, so I'll watch the match BECAUSE I WANT TO WATCH THE MATCH. If I don't watch the match, nothing bad will happen.
that's fine. Do stuff because you want to do stuff, not because OCD says so.

Situation b: I feel terrible, and am worried that if my anxiety doesn't come down, something bad will happen. I MUST get my anxiety down, so I'll watch the football to get rid of the thoughts and anxiety.
That's not fine, its ocd running your life. you are doing stuff because you fear the consequences of not doing it.

 

 

Question from Legend

Hi Paul, As i have recovered from my ocd, would you say that a recovered ocder would make a good therapist, and what type of training would be involved, and how long would it take ...

ashley(legend)

Paul's Reply:
Hmm, tough one. I don't want to generalise too much, but probably have to The answer is yes....and no.
Clear? ;-)

I'll try to explain. In training, I emphasise the importance of being able to make sense of the person's problems, and often having been a sufferer yourself can help. However, the problem sometimes is that the person who has suffered from a particular problem makes the sometimes mistaken assumption that someone they are trying to help has the same reactions as them, leading to "what was good for me surely must be good for you" type of assumption.

Fortunately, good training, good supervision and good sense can all help to make sure that this doesn't happen. So, on balance, there is probably a slight advantage to having been a sufferer.

Training: depends on what training you already have. Most therapists have a core profession. If not, then a counselling qualification might be appropriate.

 

 

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