Still Checking, Still Not Sure

A common compulsion in OCD is checking to make sure that something was done correctly: turning off the stove, copying an address, shutting the refrigerator, locking the door, and so forth.

We can never know with absolute certainty that we’ve done something right, so many people with OCD end up checking repeatedly, sometimes for hours. The lost time is bad enough, and most people find that they actually feel less certain that they’ve done it right.

How can it be that more checking yields greater uncertainty? A recent study addressed this paradox by having participants perform a computerized task and then check to make sure they’d done it correctly. The study authors predicted that repeated checking would lead to quicker, more automatic checking as well as less confidence in one’s memory of having done the task correctly. 

The study’s results did show that repeated checking resulted in faster checking and less memory confidence. It was unclear whether the faster, more automatic checking caused the greater uncertainty, and more work remains to be done to understand how checking leads to uncertainty. Additionally the participants were undergraduate students, not necessarily individuals with OCD, which calls into question the applicability of the findings to checking in OCD.

What’s the bottom line for OCD sufferers? As most people with OCD-related checking have found, the best solution is not to start checking in the first place. Generally it’s easier to walk away from an urge to check than to “check a little” and then walk away.

Of course, it’s easier to say “don’t check” than it is to resist the compulsive urges. Exposure and response prevention (ERP) for OCD is designed to assist a person’s efforts to break free of compulsive behaviors. Over time it typically gets easier not to check, leading to less distress and more time to do the things a person actually cares about.


Elaine C. P. Dek et al. (2014). Automatization and familiarty in repeated checking. Journal of Obsessive-Compulsive and Related Disorders, 3, 303-310.

Pure O?

Obsessive-compulsive disorder, as the name suggests, involves both obsessions–intrusive worries about bad things happening–and compulsions, which are intended to prevent the feared outcomes.

Or does it? Based on the diagnostic criteria in DSM-5, OCD can be diagnosed if obsessions or compulsions are present. Accordingly, a significant number of OCD sufferers describe themselves as “pure obsessional” or “Pure O,” meaning they have obsessions without compulsions.

However, what appears to be “Pure O” typically turns out to involve mental compulsions (like saying a ritualized prayer), which functionally are the same as compulsions that others can see (such as repetitive hand washing). Both types of compulsions are meant to reduce the chance of something bad happening, and to reduce the person’s distress.

Every instance of “Pure O” that I’ve encountered has included the presence of mental compulsions, which is in line with research findings. In a study (1) of over 1000 OCD sufferers, every single person was found to have both obsessions and compulsions–including the 1 percent of individuals who initially thought they had only obsessions. A related study (2) reported that individuals who supposedly have “Pure O” engage in mental compulsions and reassurance seeking.

The study authors strongly recommended that the updated OCD criteria reflect their, and others’, findings. However, for reasons that are unclear the DSM-5 work group that updated the OCD criteria chose not to require the presence of both obsessions and compulsions for an OCD diagnosis.

Does it matter that “Pure O” actually includes rituals, or is it an academic distinction without a difference? In practice it probably matters a great deal. The psychological treatment of choice for OCD is exposure and response prevention (ERP), and preventing the compulsive response is a crucial part of the treatment. If the OCD sufferer (or therapist) doesn’t recognize mental compulsions and reassurance seeking as compulsions, then treatment will not effectively deal with these behaviors. As a result the person is likely to stay stuck with the OCD.

When the compulsions are recognized for what they are, they can be treated just like any other ritual in ERP (see this related post).

1. Leonard, R. C., & Riemann, B. C. (2012). The co-occurrence of obsessions and compulsions in OCD. Journal of Obsessive-Compulsive and Related Disorders, 1, 211-215.
2. Williams, M. T., Farris, S. G., Turkheimer, E., et al. (2011). Myth of the pure obsessional type in obsessive-compulsive disorder. Depression and Anxiety, 28, 495-500.

PTSD Awareness Day

June 27th is National PTSD Awareness Day. All of us know people who’ve been through horrifying traumatic events–things like assaults, combat, accidents, and natural disasters. The person may have experienced the event directly or witnessed it, or learned about something terrible happening to a loved one. About 1 out of 10 people who survive a trauma will develop posttraumatic stress disorder (PTSD).

Common symptoms of PTSD include being very upset by the memory of what happened, having nightmares, and other ways in which the trauma memory keeps coming back; trying hard not to think about the memory or be in situations that bring up the memory; blaming oneself for “allowing it to happen” or feeling weak and incompetent; problems sleeping and focusing; anger and reckless behavior; and being constantly “on guard” and easily startled, among others.

Even for people who don’t develop PTSD, these kinds of reactions are really common in the aftermath of a trauma. PTSD involves stress reactions that last longer than a month.

Yesterday I had the privilege of speaking about cognitive-behavioral therapy for PTSD at the SUNY Upstate Medical Center, Department of Psychiatry grand rounds. I tried to emphasize the good news that highly effective treatment is available that can help most PTSD sufferers get their lives back. For example, in a large PTSD treatment study by Dr. Edna Foa and colleagues (2005), the average patient who received cognitive-behavioral therapy (CBT) saw their symptoms go down by more than 70% after 8 to 12 sessions.

The first step toward effective treatment is recognizing the need for it. If you or someone you love might have PTSD, it may be helpful to seek a professional consultation. If treatment is necessary, it’s a good idea to find a therapist who uses evidence-based treatment. You can ask the person what form of treatment s/he uses for PTSD and whether the treatment has research evidence to back it up. CBT programs have the most evidence that they work, and include treatments like prolonged exposure, eye movement desensitization and reprocessing (EMDR), and cognitive processing therapy.

With proper diagnosis and treatment a person with PTSD can expect to feel better and rejoin life.

New Book: Overcoming OCD

When Janet Singer’s son was diagnosed with severe OCD, she discovered like so many parents that effective OCD treatment is frustratingly hard to find. Eventually her son recovered through exposure and response prevention (ERP). Janet is determined to make it easier for parents and OCD sufferers to connect with the help they need. She maintains a terrific blog about OCD and wrote a book about her son’s journey to recovery.

I was very honored that Janet asked me to join her as a co-author, adding commentary throughout the book on various OCD topics. The book was recently accepted for publication and is due out in January 2015. Our hope is that Overcoming OCD will be a helpful resource to individuals with OCD and their loved ones. More information about the book is available on Janet’s blog here.


Good Sleep Is Low-Tech

Earlier this month my students and I completed a research study on college students’ sleep. One of the things we asked students was how often they used various forms of technology (e.g., tablets, cell phones) in the hour before bedtime. We found a highly significant correlation between technology use and sleep problems, confirming results from earlier studies showing that technology use is associated with worse sleep.

One recent study that also found links between technology use and poor sleep was the National Sleep Foundation’s 2014 Sleep in America Poll, titled “Sleep in the Modern Family.” The study of over 1100 parents found that kids who used tablet computers in their bedrooms at night got on average almost an hour less sleep. Similar results were reported for use of TVs in the bedroom. Dramatic effects were also found for leaving on electronic devices at night; kids who left on 2 or more devices had nearly triple the rates of parent-reported “fair or poor” sleep compared to those who never left on any electronics. The full report is available here.

These results by themselves don’t tell us if using electronics in the bedroom causes poor sleep. It could be that people who sleep badly are just more likely to turn to their TVs or smartphones when they’re having trouble sleeping–in other words, electronic use might be a consequence of bad sleep rather than a cause. Future work remains to be done to figure out exactly why more technology use equals worse sleep.

Nevertheless, there are reasons to believe that using cell phones and other forms of technology interferes with sleep. For one, the blue light that the screens emit has been found to disrupt sleep. Additionally, it’s not uncommon for people to receive–and respond to–text messages in the middle of the night. If a cell phone isn’t in the bedroom, or is turned off, then there’s no risk of being woken up by it. So the safest option is to banish technology from the bedroom, and enjoy a relaxing and low-tech environment for sleeping.

My student collaborators at Haverford College were recent grads Noemi Agagianian, Tami Mau, Kylie O’Neill-Mullin, and Gabe Olsen.

There’s Hope for Bad Sleep

Earlier this month I attended a 3-day advanced seminar on cognitive-behavioral therapy for insomnia (CBT-I) in Philadelphia, along with another 40 or so therapists who provide CBT-I. It was led by Drs. Michael Perlis from Penn and Donn Posner from the VA Health Care System at Palo Alto.

The seminar was a great chance to learn about the latest research in the area, meet other clinicians working in a wide variety of settings, and hear about ways that CBT-I can be helpful.

Two things stood out to me during the seminar. One was how effective CBT-I can be for most people. We heard from many attendees about individuals they had worked with who were struggling not only with bad sleep but with medical and psychological difficulties. In most cases the treatment helped people to fall asleep faster and sleep more soundly through the night.

The other–and less fortunate–thing that struck me was that this treatment, like so many of the best-supported psychological treatments, is relatively hard to find. In that way it’s similar to most of the CBT programs for conditions like panic disorder, PTSD, and OCD–the most effective treatments generally aren’t that easy to find.

Fortunately part of the seminar focused on novel ways to bring CBT-I to people who need it. For example, there are Internet-based programs that can make CBT-I more widely available. The treatment also can be delivered by telephone or video conference such that patient and therapist don’t have to be in the same room, or even the same city. And of course training more therapists to deliver CBT-I is a crucial step in making this highly effective treatment available.

PTSD Treatment for Teen Survivors of Sexual Abuse

Dr. Katherine Dahlsgaard, Lead Psychologist at The Anxiety Behaviors Clinic and the Children’s Hospital of Philadelphia, recently wrote an article that nicely summarized recent findings from a research study on PTSD treatment for teenage girls who experienced sexual abuse.

The study was conducted in Philadelphia at the Center for the Treatment and Study of Anxiety, where I worked from 2008-2012. An incredible amount of work and coordination went into this well-executed study, and the results have important implications for teens in need of effective PTSD treatment. They show that cognitive-behavioral therapy (in this case, prolonged exposure), which is known to be very effective for treating adult survivors of trauma, can also be life changing for teenagers with PTSD.

Dr. Dahlsgaard’s write-up is available here.

Stressed and Sleepy in America

The American Psychological Association recently released the results of its “Stress in America” survey, based on responses from nearly 2000 adults and over 1000 teens. I want to highlight some of the findings related to stress and sleep.

We all know that feeling stressed can get in the way of sleep. Who can sleep well when the mind is agitated and the body is restless? Importantly, the reverse is also true: Lack of sleep leads to stress. So when we’re stressed and sleepless, we can fall into a vicious circle where stress and lack of sleep feed each other.

The effects of lack of sleep are striking. When we don’t sleep enough we’re more likely to neglect responsibilities, lose patience, skip exercise, and yell at the people we love. These behaviors can further compound our sense of being overwhelmed.

So what can we do when we’re feeling stressed out and are having a hard time sleeping? First we have to recognize when our stress has risen to an unhealthy level. If it has, there are effective ways to manage the stress. For example, there are mindfulness-based stress reduction programs that most people find to be extremely helpful for managing their responses to stress. (For example, Penn has a very well regarded program; check it out here.) Working with a therapist can also be very helpful in learning how to make changes to reduce our stress, or to deal better with the stress of life that’s unavoidable.

Thankfully as we learn to manage stress, sleep also tends to improve, and better sleep leads to a better sense of being able to cope.

The press release is available here:

Your Dreaming Brain

Some people seem to remember their dreams every night, whereas others rarely remember any dreams. What accounts for these differences?

A recent study by a group of French neuroscientists provides a potential explanation. The researchers recruited subjects who remembered their dreams either often or rarely, and compared the brain activity of these two groups during sleep and during wakefulness.

Two brain areas were more active in high dream recallers during rapid eye movement (REM) sleep, when our most vivid and memorable dreams occur: the temporoparietal junction (where the temporal and parietal lobes meet, as the name suggests) and the medial prefrontal cortex in the frontal lobes.

So what does it mean that there was greater activity in these areas? The study authors offered some possible interpretations. One possibility is that these brain differences reflect something meaningful about the dreams themselves. In particular, they might indicate that people who often remember their dreams tend to have more exciting dreams.

Another explanation the authors propose is that individuals who remember their dreams more often are more likely to awaken during the night, allowing them to encode their dreams into memory (since memory generally is “turned off” during sleep).

Of course, these two explanations aren’t mutually exclusive. It could be that more interesting dreams are more likely to awaken a person, making their dreams doubly likely to be recalled the next day.

Incidentally, these two explanations are consistent with why REM dreams are more likely to be remembered than are dreams during non-REM deep sleep. Although we can dream in any sleep stage, our REM dreams tend to be the most gripping, and we’re also more likely to awaken briefly after a REM stage than after a stage of deep sleep, making it more likely that we’ll remember the dream.

So for people who wish they had more exciting dreams, perhaps better sleep is a nice consolation prize!

Reference: J.-B. Eichenlaub et al. (in press). Resting brain activity varies with dream recall frequency between subjects. Neuropsychopharmacology.

It Turns Out Smoking Is Bad for You

A surgeon general’s report released today underscores what’s been known for decades–that being a cigarette smoker is the single best way to get sick and die young. In the past 50 years, over 20 million premature deaths in the US can be linked to smoking.

The report specifies even more diseases that seem to be caused by smoking, on top of the obvious ones like lung cancer and emphysema. The list now includes such wide ranging conditions as macular degeneration (a common cause of blindness), diabetes, erectile dysfunction, and rheumatoid arthritis, among others. Being exposed to secondhand smoke increases the risk for stroke.

And yet, an estimated 45 million Americans still smoke. Part of the reason may be that smokers–especially ones who are young and haven’t started hacking and coughing–may feel like “it won’t happen to me.”

But what about smokers who have terrible smoking-related health problems, like cancer of the lung, head, or neck? If ever there were a group that would be motivated to quit, this would be it! Nevertheless, a recent review found that even these individuals were unlikely to stop smoking. For example, one of the larger studies in the review found that 70% of cancer patients continued to smoke–even after getting smoking cessation treatment.

As I discussed in a previous post, quitting smoking is really hard, and simply being motivated often is not enough to get a person there. While existing treatments help, there’s obviously plenty of room for improvement. Researchers and clinicians continue to work to develop more effective medications and psychotherapies. With effective treatment, more ex-smokers get to enjoy added years of better quality life.