J is a 28-year-old, married man who works as a scientific programmer. At presentation to our Center, he reported repetitive and intrusive thoughts about becoming contaminated by chemical substances that would cause him to “flip out” or “lose [his] mind.” As a result, he washed his hands excessively (approximately 35 times per day), avoided eating prepared foods at restaurants, and checked all foods and beverages for potential signs of “tampering” before consuming them. He often felt anxious as a result of these thoughts and sometimes experienced panic attacks when he felt he had been contaminated.
J appeared to be especially sensitive to the physical sensations of anxiety, such as increased heart rate, tingling sensations in his extremities and face, and feelings of unreality. When these feelings occurred, he misinterpreted them as “proof” that he had accidentally ingested a dangerous substance and, as a result, became increasingly anxious and afraid he would ultimately lose touch with reality or possibly die. He avoided over-the-counter medications, alcohol(Drug information on alcohol), caffeine(Drug information on caffeine), and “energy” drinks. J expressed concern that ingesting these substances would produce physical sensations and subsequent panic that he would be unable to control. Furthermore, he felt that these substances would in some way “alter [his] nervous system” so that he would be more prone to the onset of anxiety and panic in the future. While J reported having obsessive thoughts occasionally during childhood, the onset of his current symptoms occurred following excessive use of methylphenidate(Drug information on methylphenidate) that resulted in hospitalization for acute intoxication.
In addition, J reported difficulty in engaging in social situations. More specifically, he experienced difficulties in speaking in front of groups or in formal settings, being assertive, and playing sports in front of a crowd. When asked what he believed would happen in these situations, he expressed concern about saying something stupid, being too nervous to talk coherently, or that he would be rejected. These fears were interfering with his ability to be more outgoing at work, participate in group projects, and share his ideas with others. He avoided meetings and would turn down opportunities to train more junior members of his work group. J reported always being shy but noted an increase in social anxiety during high school. He had had no previous pharmacological or psychological treatment.
The diagnosis was obsessive-compulsive disorder (OCD) and social phobia. Sixteen sessions of individual treatment following the UP model were conducted over 20 weeks. Following psychoeducation on the nature of emotions, we focused on increasing J’s awareness of his emotions and his reactions to them as they occur. As we conceptualized his attempts to suppress emotional experiences as paradoxically prolonging and increasing the intensity of the emotional response, nonjudgmental and present-focused awareness of emotions was presented as a way to counteract this maladaptive response pattern. In-session mindfulness exercises were conducted to elicit both negative and positive emotions and to help J develop and practice these skills. We began with more nonspecific stimuli, then moved to material that was more personally relevant. For instance, J was first asked to listen to a compact disc containing emotionally provoking music. Shortly thereafter, he watched scenes from movies depicting negative drug experiences. He was instructed to be aware of his emotions without labeling or judging them while reducing attempts at suppression and avoidance—to “actively do nothing” in response to his emotions.
The next phase of therapy consisted of identifying and subsequently challenging core cognitive themes regarding his obsessive thoughts and social fears. For instance, when J was unable to directly watch his food being prepared at a restaurant, he experienced thoughts that it had in some way been tampered with, even though there was little evidence to support his assumption. By challenging the likelihood of this belief, and by introducing alternative appraisals, he learned to question the credibility of his initial obsessive belief and, as he described, was able to separate from the thought in a manner that allowed him to choose a different behavioral response. Maladaptive patterns of emotional avoidance were identified.
Some of his avoidance behaviors were more obvious, such as excessive washing and his refusal to eat at restaurants, while other behaviors were more subtle, such as distracting himself when experiencing intrusive thoughts or images and rationalizing when he believed he had been contaminated. At work, he avoided meetings and engaged in additional behaviors to make certain situations more “tolerable,” such as reading work-related materials at lunch to dissuade his coworkers from engaging him in conversation. While J initially viewed his avoidance strategies as somewhat successful in regulating his anxiety, he eventually came to appreciate the long-term negative consequences of these strategies and learned how to respond in a way that allowed him to directly challenge his beliefs regarding the perceived dangerousness of the situation.