Skin Picking Disorder: How to Diagnose and Treat It

“Hello again—here we are scabby and red,” wrote Tallulah Willis in the caption of a recent bare-faced selfie on Instagram. She continued, “Feeling out of control so zeroing in on something I CAN control, thus fingernails met face, facialist and dermatologist sighed, and the healing process commenced.”

It’s not the first time illustrator, fashion designer, and mental health advocate Willis has gotten candid about her battle with skin-picking disorder, also known as excoriation disorder or dermatillomania, which is a mental illness related to obsessive-compulsive disorder (OCD) that consists of repetitively picking at one’s own skin. But her willingness to speak publicly about the struggles of living with skin-picking disorder, which affects as many as 1 in 20 people according to the International OCD Foundation and is experienced by women more often than men, continues to be invaluable in raising awareness and lessening stigmas around it.

Given the impact that the global pandemic has had on mental health, it’s a fitting time to delve deeper into what skin-picking disorder is, how it manifests physically and mentally, and what can be done to treat it. Here, three different experts weigh in.

What is skin-picking disorder?

“We all pick at our skin on occasion, but for individuals with skin-picking disorder, it can be very difficult to stop,” explains Lisa Zakhary, M.D., Ph.D., the medical director of the Massachusetts General Hospital (MGH) Center for OCD and Related Disorders (CORD) and co-founder of the MGH Comprehensive Skin Management Clinic. According to Zakhary, skin-picking disorder is characterized by recurrent picking, repeated attempts to stop picking, and consequential distress or impairment. The most common sites of picking include the face, back, arms, legs, hands, and feet, and people most typically use their fingernails. Psychologist Dr. Jenny Yip, founder of the Renewed Freedom Center, underlines that skin-picking disorder is a body-focused repetitive behavior (BFRB), which includes related disorders such as nail-biting, picking at lips, and trichotillomania. While under the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), body-focused repetitive behavior are categorized as part of obsessive-compulsive-related disorders, and there are some similarities, they are not completely the same.

What are the physical symptoms of skin-picking disorder?

From a dermatological perspective, a tell-tale sign is numerous secondary lesions of the skin, such as scratches, erosions, ulcers, and scabs, without the presence of primary skin disease. “Chronic skin picking can lead to an endless cycle of itching/scratching, skin breakdown and infection, and many aesthetic stigmata, including hyperpigmentation, reactive skin thickening, and picker’s nodules,” explains NYU Langone dermatologist Evan Rieder. In many instances, those who suffer from skin-picking disorder tend to pick at any imperfections that feel very tactile and visual. “If they see something that looks imperfect, like bumps on the skin, for example, they will have an urge to pick at it,” explains Yip. “It’s a similar feeling as to when you have a scab that’s ready to fall off, and you have an intense urge to get rid of it. Then magnify that urge by a hundred—that’s what it feels like to have skin-picking disorder.”

In spreading awareness of skin-picking disorder, Zakhary seeks to address the common misperception that it’s relatively mild or, as she puts it, is “no worse than any other bad habit like looking at a screen right before bed.” In addition to the severe physical consequences, many who suffer from skin-picking disorder avoid certain social situations for fear that their skin picking will be discovered. “This can impact home and work life and lead to depression and anxiety,” says Zakhary.

Shame and guilt are also part of the psychology of battling a skin-picking disorder, stresses Yip. “People who have skin picking disorder do not enjoy picking their skin—often, they’ll have tried to stop without success in the past,” she explains. “Therefore, when it does happen and it reaches a point of bleeding, there’s a lot of embarrassment, shame, and guilt. It becomes a vicious cycle because if you’re feeling shame, embarrassment, and guilt, you’re going to feel distressed by it, which is a trigger for skin picking. So then you become more stressed, and your go-to response to dealing with stress is picking.”

How might lockdown be impacting those who suffer from skin-picking disorder?

“The two main triggers of picking are either when a person is bored and underwhelmed, or a person is distressed and overwhelmed,” explains Yip. “The pandemic posed as the perfect space for those two things. You’re stressed about the pandemic, all of these regulations, and people dying around you, but you don’t have anything to focus on because everyone was in quarantine.” In tandem, Rieder has seen how the increase in screen usage and Zoom has had adverse effects on patients’ self-image. “I have been seeing an uptick in people scrutinizing the details of their skin, much of which is due to an over-reliance on social media and video conferencing,” explains Rieder. “Some of that behavior is paired with skin picking and manipulation to try to improve slight or perceived imperfections in the skin.”

What are the best ways to treat skin-picking disorder?

While skin picking is typically a chronic condition with occasional flares, dermatologic treatments, therapy, and medications can help—but different patients will need different support. “Understanding one’s triggers for picking can help guide which treatment to pursue,” explains Zakhary. “For example, individuals whose picking is triggered by a skin condition such as acne may benefit from a dermatologic consultation. However, if picking is triggered by sadness, anger, anxiety, or more of a general urge, consultation with a mental health professional is recommended.”

Online CBT effective against OCD symptoms in the young

IMAGE: First author Kristina Aspvall.
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Credit: Ulf Sirborn

Obsessive-compulsive disorder (OCD) in children and adolescents is associated with impaired education and worse general health later in life. Access to specialist treatment is often limited. According to a study from Centre for Psychiatry Research at Karolinska Institutet in Sweden and Region Stockholm, internet-delivered cognitive behavioural therapy (CBT) can be as effective as conventional CBT. The study, published in the prestigious journal JAMA, can help make treatment for OCD more widely accessible.

Obsessive-compulsive disorder (OCD) is a potentially serious mental disorder that normally debuts in childhood.

Symptoms include intrusive thoughts that trigger anxiety (obsessions), and associated repetitive behaviours (compulsions), which are distressing and time consuming.

Early diagnosis and treatment are essential to minimise the long-term medical and socioeconomic consequences of the disorder, including suicide risk.

The psychological treatment of OCD requires highly trained therapists and access to this kind of competence is currently limited to a handful of specialist centres across Sweden.

Earlier research has shown that while CBT helps a majority of young people who receive it, several years can pass between the onset of symptoms and receipt of treatment.

Researchers at Karolinska Institutet have spent three years evaluating whether low-intensity internet-delivered CBT for children and adolescents with OCD can be used in a stepped care model in order to improve access to treatment without compromising its efficacy.

The two-centre study was conducted in collaboration with Child and Adolescent Mental Health Services in the Stockholm and Vastra Gotaland regions and comprised 152 participants between the ages of eight and 17.

The participants were randomly assigned to one of two groups. One group first received therapist-guided digital CBT, and the other (control) received standard CBT through weekly in-person sessions with a therapist.

Each group received treatment for a period of 16 weeks, supported by their therapists and parents.

The researchers then followed up the participants three months after treatment in order to evaluate the therapeutic effect on OCD symptoms, daily function and depressive symptoms.

After the 3-month follow-up, the participants in both groups deemed in need of additional support received up to 12 extra sessions of conventional CBT up until the 6-month follow-up.

The results showed that stepped digital CBT reduced the participants’ OCD symptoms as much as conventional CBT. Approximately 70 per cent of participants in both groups were treatment responders at the 6-month follow-up.

“The advantage of the stepped care approach is that it makes it easier for us to reach out to more children and adolescents with OCD in need of help,” says the study’s first author Kristina Aspvall, psychologist and researcher at the Centre for Psychiatry Research, part of Karolinska Institutet’s Department of Clinical Neuroscience.

Crucially, the stepped care group required fewer resources: therapists spent an average of 9 hours per participant in the stepped treatment group and 14 hours per participant in the control group.

“The study demonstrates the potential of technology when it comes to increasing access to evidence-based therapy for young people with OCD,” says principal investigator Eva Serlachius, adjunct professor at Karolinska Institutet’s Centre for Psychiatry Research. “By offering low-intensity digital intervention as the first step of treatment, clinics can save precious resources and devote their limited time to treating more patients or focusing on more complex cases.”

Internet CBT for OCD is currently being implemented in regular care through Region Stockholm’s Child and Adolescent Mental Health Services (BUP Internetbehandling), which also collaborates with other health authorities across Sweden. The treatment was developed by researchers at Karolinska Institutet and Region Stockholm.


The study was financed by FORTE (the Swedish Research Council for Health, Working Life and Welfare), ALF Medicin, the Jane and Dan Olsson Foundation, the Queen Silvia Jubilee Fund, the Swedish Mental Health Fund and the Fredrik and Ingrid Thuring Foundation.

Publication: “Effect of an internet-delivered program vs in-person cognitive behavioral therapy on obsessive-compulsive disorder symptoms in children and adolescents: a randomized clinical trial”, Kristina Aspvall; Erik Andersson, Karin Melin, Lisa Norlin, Viktor Eriksson, Sarah Vigerland, Maral Jolstedt, Maria Silverberg-Morse, Lena Wallin, Filipa Sampaio, Inna Feldman, Matteo Bottai, Fabian Lenhard, David Mataix-Cols, Eva Serlachius. JAMA, online 11 May 2021, doi: 10.1001/jama.2021.3839.

What is COVID-19 anxiety syndrome?

As lockdowns and restrictions ease in various locations, some people find it extremely challenging to reacclimate to “normal” life. As the pandemic recedes, some consider this phenomenon as the next emerging mental health crisis.

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COVID-19 anxiety syndrome is an emerging phenomenon defined by compulsive symptom checking and avoiding leaving the house, even when the health risks are minimal. Paul Frangipane/Bloomberg via Getty Images

Over a year has passed since SARS-CoV-2 began to spread across the world. Its appearance, which first caused mild concern, soon turned into serious worry as more people received a diagnosis of COVID-19.

In the beginning, scientists knew very little about this novel virus and the disease it caused. The unknowns and the virus’s remarkably rapid spread incited fear among health professionals, scientists, and the public.

Soon, restricted travel, lockdowns, mask mandates, and physical distancing protocols were implemented as a tactic to slow COVID-19’s spread. Widespread media coverage detailed every nuance of an ever-changing pandemic landscape as world leaders and health experts waged war on this invisible threat.

Worldwide, there have been over 150 million confirmed cases of COVID-19, with just over 3 million deaths attributed to the disease. According to official projections, in some countries, such as the United States, the rate of new SARS-CoV-2 infections is gradually declining.

This decrease is likely due to increased herd immunity and the introduction of vaccines. To date, approximately 1 billion vaccine doses have been administered across the globe.

As a result, some countries, such as the United Kingdom, are beginning to soften protocols initially put in place to stop the spread of the virus. As lockdowns lift, many people who were unable to leave their house are now going out and enjoying life as best they can while still being mindful of safety.

Yet, for some, going back out and mixing with other people is a concept filled with fear and anxiety. Despite vaccines and a decrease in disease prevalence, some people experience what scientists call COVID-19 anxiety syndrome.

Symptoms of this syndrome mimic those of other mental health conditions, including anxiety, post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD). And, the pandemic and related factors appear to be the cause.

In this Special Feature, Medical News Today takes a closer look at this phenomenon, how it occurs, and what the latest research says. We also talked to environmental psychologist and well-being consultant Lee Chambers, M.Sc., M.B.Ps.S. Chambers shared his tips on how to manage this emerging mental health challenge.

CBD shows promise in the treatment of anxiety — but more research is needed, particularly among women

A new report published in the journal Cannabis and Cannabinoid Research presents an overview of the clinical findings concerning the effectiveness of cannabidiol (CBD) in the treatment of anxiety. While the report suggests that CBD may offer a safe and effective treatment for anxiety, the authors highlight the need for additional research among the female population.

The research team behind the review, led by Madison Wright, notes that anxiety disorders are the most common mental health disorders worldwide. Despite the pervasiveness of anxiety disorder diagnoses, existing behavioral treatments offer limited effectiveness and the current pharmacological treatments carry unwanted negative consequences.

A growing research trend has focused on the anti-anxiety properties of cannabidiol (CBD) — a compound found in the Cannabis plant. Unlike tetrahydrocannabinol (THC), CBD does not produce a “high”, and studies have yet to uncover any evidence of abuse or dependence in humans.

“Anxiety disorders are highly prevalent worldwide and treatment options tend to have adverse side effects and the majority of patients do not achieve complete remission,” explained Wright, a doctoral student affiliated with the Centre for Addiction and Mental Health and the University of Toronto.

“Following the recent push to legalize cannabis in many jurisdictions, CBD has gained a lot of attention from the public and scientific community for its potential therapeutic properties. Given the data demonstrating that CBD is well tolerated and demonstrates little potential for abuse or dependence in humans, we were interested in reviewing the animal and human literature on its use as a treatment option for anxiety disorders.”

Wright and her colleagues reviewed the current findings from both pre-clinical and clinical trials to shed light on the potential role of CBD in the treatment of anxiety.

First, findings from pre-clinical animal studies show that low to medium doses of CBD produce anxiety-reducing effects, while high doses increase anxiety. Animal research also offers evidence that the anxiety-relieving effects of CBD involve the serotonin receptor 5-HT1A. While on the whole, this research shows compelling support for CBD as an anxiety treatment, the researchers note that these studies have only been conducted among male animals.

Next, clinical studies among patients with social anxiety disorder have found anxiety-reducing effects with single doses of either 400 or 600 mg of CBD. During a public speaking simulation task, these doses were found to lower anxiety symptoms, reduce cognitive impairment, and reduce discomfort associated with one’s speech performance. A collection of brain imaging studies additionally revealed that CBD intake alters blood flow in the amygdala, hippocampus, hypothalamus, and cingulate cortex — four brain structures implicated in anxiety.

“The main takeaway from this review is that early research indicates that CBD may reduce anxiety in healthy volunteers,” Wright explained. “The results from studies in animals are promising, suggesting that CBD may reduce anxiety, stress, panic and compulsive-like behaviors.”

“Preliminary evidence from human studies demonstrates that CBD may reduce anxiety in healthy participants and patients with social anxiety disorder. It is important to emphasize that this data is preliminary and more research is required.”

“There are still many questions that need to be addressed and rigorously studied,” Wright said. “The only human studies examining CBD as a treatment for anxiety have been conducted in patients with social anxiety disorder, therefore, research is needed in patients with other anxiety disorders, such as generalized-anxiety disorder and panic disorder. Secondly, much remains unknown about the use of CBD as a treatment for anxiety, such as the most effective route of administration, appropriate doses to be used, and its long-term safety and efficacy.”

While reviewing these findings, Wright and her colleagues also pinpointed another important issue. Although males and females appear to experience anxiety differently, no clinical trials have examined sex differences in the anxiolytic effects of CBD. Most studies have examined male participants, but evidence suggests that women tend to experience worse symptoms and a higher likelihood of having an additional diagnosis. Males, on the other hand, are more likely to experience anxiety alongside alcohol and substance abuse.

“The rates of anxiety disorders are nearly doubled in females compared to males, there are differing anxiety-related symptoms and responses to psychotropic medications between the sexes, and CBD has different effects on the body in males and females,” Wright explained. “Therefore, it is important that future research examines sex and gender differences in the utility of CBD as a potential treatment for anxiety disorders.”

The researchers noted that additional trials will be important to examine the outcomes of CBD among patients with other anxiety-related disorders, such as general anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder. They also suggest that future studies should explore the optimal dose and administration route for CBD and assess its safety in the long term.

“Although this area of research appears to be promising, it is far too early to unequivocally conclude that CBD can be used to treat anxiety. More research is needed to guide physicians and the public in the safe and effective use of CBD as a treatment for anxiety,” Wright concluded.

The study, “Use of Cannabidiol for the Treatment of Anxiety: A Short Synthesis of Pre-Clinical and Clinical Evidence”, was authored by Madison Wright, Patricia Di Ciano, and Bruna Brands.

Anxiety in Children: Signs and Symptoms To Look For

Everyone experiences anxiety from time to time, but not everyone experiences it the same way. Children are no exception.

In some instances, anxiety in children is related to a specific event they fear to face. For example, an upcoming sports game or a big presentation at school.

Other times, your child might feel anxious all the time and in most situations.

When anxiety symptoms last for a while and they’re not addressed, they might become a challenge for your child or teen.

According to the Anxiety Disorders Association of America (ADAA), the average age for an anxiety diagnosis in children is between 4 and 8 years old. This often coincides with the time a child starts school. But this is not the only time a child might develop anxiety symptoms.

A younger child might not know how to express their emotions. An older child might feel you won’t understand them, even if they tried to explain. This is natural and not uncommon.

Learning to recognize the specific symptoms of anxiety in children can help you provide the support they need and when they need it.

There are a few types of anxiety disorder, and each of them can have its own symptoms.

Common anxiety disorders in children include:

  • Generalized anxiety disorder (GAD)
  • Post-traumatic stress disorder (PTSD)
  • Social anxiety disorder
  • Specific phobias
  • Obsessive-compulsive disorder (OCD)
  • Panic disorder
  • Selective mutism
  • Separation anxiety

Some children will develop symptoms of one or more anxiety disorders, but it doesn’t mean they have the condition. If the symptoms are temporary, it is likely not an anxiety disorder.

In general, symptoms of anxiety in children may include:

  • bed-wetting
  • needing constant reassurance
  • complaining of a stomach ache or other pains, particularly before specific activities or events
  • avoiding everyday situations, like school or social events
  • difficulty eating or sleeping
  • tearfulness without a reason
  • clinginess (especially if this is a new behavior in the child)
  • angry outbursts
  • being fidgety or unable to rest
  • difficulty concentrating
  • difficulty doing chores or schoolwork
  • physical symptoms like shaking or flushing

These symptoms may or may not be part of an anxiety disorder. Only a mental health professional can offer a correct diagnosis.

Challenges in the diagnosis in Tourette syndrome patients | NDT


According to DSM-5, Tourette syndrome (TS) is defined by the presence of at least one vocal and multiple motor tics persisting for more than 1 year with childhood onset. In almost 80% of patients, psychiatric comorbidities co-occur, the most frequently being attention deficit/hyperactivity disorder (ADHD), obsessive-compulsive behavior (OCB) or obsessive-compulsive disorder (OCD), depression, anxiety, rage attacks, and self-injurious behavior (SIB).1,2 The prevalence of TS ranges – depending on age – from 0.3% to 1%.3–5 Tics are sudden, rapid, recurrent, non-rhythmic motor movements or vocalizations.6 Alternatively to the term vocal tics, the name phonic tic is used. Both motor and vocal tics can be further divided into simple and complex tics. Depending on the movement pattern motor tics, in addition, can be classified as tonic, clonic, or dystonic tics. In addition, some specific types of complex tics include echolalia (repetition of sounds, words or phrases pronounced by others), echopraxia (repetition of gestures executed by others), palilalia (spontaneous repetition of one’s own sounds, words or phrases sometime resembling stuttering or speech blocking tics), palipraxia (repetition of one’s own gestures), coprolalia (shouting of obscene words or phrases), and copropraxia (execution of obscene postures or gestures). Finally, tics are typically characterized by brief preceding premonitory sensations, temporal suppressibility, and a rostro-caudal distribution.

While in the majority of patients the diagnosis of a primary tic disorder is easy to make, in some patients the differential diagnosis is more difficult and complex. Motor tics must be differentiated not only from other hyperkinetic movement disorders, such as stereotypies, myoclonus, paroxysmal disorders, and epileptic seizures, but also hyperactivity due to ADHD and repetitive behaviors and rituals belonging to the OCD spectrum, and, finally, from functional movements. Interestingly, the clinical spectrum of OCB/OCD in TS differs from symptoms in pure OCD. This has been described as “tic-related OCD” mainly associated with “just right” phenomena.7,8 However, tics and “just right” phenomena may also occur coincidentally.

In this review we want to give recommendations for the diagnosis and assessment of tics and OCD in patients with TS. To identify all relevant articles, we conducted a systematic review yielding to find publications reporting about OCD phenomena in TS. Furthermore, recommendations given by the European Society for the Study of Tourette Syndrome (ESSTS) have been taken into consideration.9 Finally, we address challenges that one could encounter in the management of patients with overlapping tics and obsessions and/or compulsions. In this regard, we also outline differences between the OCB/OCD spectrum in TS compared to pure OCD (without tics) and briefly highlight differences in therapeutic interventions.


We conducted both a systematic as well as a narrative review of the most important aspects related to OCB/OCD in TS. Our systematic approach was based on the search in PubMed, Ovid, Web of Science, Embase and APA Psych Info conducted on February 08, 2021. We searched for articles examining the coexistence of TS and OCB/OCD using the search terms “tics” AND/OR “Tourette” AND/OR “obsessive-compulsive disorder” AND/OR “OCD” AND/OR “obsession” AND/OR “compulsion”. Reviews and meta-analyses in the area were further searched for relevant citations.

Titles and abstracts of the studies obtained through this search were examined by both authors in order to determine article inclusion. Each article was also checked for further potential references. Discrepancies were addressed by the authors through discussion. Eligibility for the systematic review was based on the following criteria: (1) studies involving patients with TS and OCD, (2) original articles, and (3) studies in humans. Articles were excluded based on the following criteria (1) meta-analyses or review papers, (2) not investigating patients with TS and OCD, and (3) animal or other preclinical studies. Several studies included data previously reported elsewhere. Data collected on each article included year, study design, number of subjects with TS and/or OCD, mean correlates of OCD in TS and the most important characteristics of OCD in TS in comparison with OCD/OCB. As a result, we identified 628 articles, out of which 57 have been included in this review. Our search strategy is illustrated in a PRISMA flow diagram (Figure 1). While in the subsequent review, we included only the most relevant studies, additionally an extensive list of all 57 publications including the most important findings is shown in Supplementary Table 1.

Figure 1 PRISMA flow diagramMoher 2009.

Diagnosis and Assessment of Tics in Tourette Syndrome

According to the guidelines published by ESSTS,9 the diagnosis of TS should be made according to newest DSM criteria. This includes the exclusion of other phenomena resembling tics as well as secondary tic disorders. Tics are characterized by a number of clinical phenomena useful to distinguish them from other neurological and psychiatric symptoms. In the majority of patients, tics are proceeded by premonitory urges defined as an uncomfortable sensation of twinging, itching, or stretching, partially or completely relieved by the tic execution. This sensation is reported to last only a fraction of a second and occurs immediately before the tic. Based on clinical experience it is believed that the topographic distribution of premonitory urges stays in line with the tic localization. Typically, patients can suppress their tics for a short period of time ranging from seconds to minutes.10 Noteworthy, the presence of premonitory urges and tics suppressibility are highly age dependent as many children do not report premonitory sensations and feel unable to suppress their tics voluntarily.

Another important characteristic is that tics are influenced by environmental factors. The majority of patients reports a temporarily tic increase during stress, emotional tension, but also when talking about tics and seeing others with tics, while tics typically decrease with concentration and relaxation. Finally, the course of tics in TS is typically waxing and waning with respect to frequency, number, intensity, complexity, and phenomenology. The typical age at onset of tics is 5–7 years.11 In most patients, simple tics proceed complex tics and motor tics usually start before vocal tics.1 In almost 70% of cases, peak tic severity is experienced in the early adolescence between 10 and 12 years of age.11–13 Thereafter, tics spontaneously improve in the vast majority of patients, but may persist into adulthood.12–14

The assessment of tics is often challenging due to their waxing and waning nature, suppressibility of tics, as well as great variability regarding their impact on quality of life. It is therefore advisable to take all available information into consideration, including interview, clinical examination, and reports by families and caregivers and – if possible and in more complex cases – home-made video recordings. Because of these well-known difficulties in assessing tics, during the last years several different measurements have been suggested for tic assessment. The authors of a systematic review published in 2017 classified available tic rating scales as “recommended”, “suggested”, and “listed”15 and recommended the following rating scales: the Yale Global Tic Severity Scale (YGTSS),16 the Tourette Syndrome Clinical Global Impression (TS-CGI),17 the Tourette’s Disorder Scale (TDS),18 the Shapiro Tourette syndrome Severity Scale (STSS),19 and the Premonitory Urges for Tics Scale (PUTS).20 Furthermore, six scales were rated as “suggested” and another five as “listed” (for more details refer to Martino et al15). Anyhow, the gold standard to measure tic severity is the YGTSS. However, there is general agreement to use only the “total tic score” (TTS, range, 0–50) of the YGTSS to assess tics. To overcome – at least in part – limitations of the YGTSS, in 2018, McGuire et al21 introduced a revised version of the YGTSS (YGTSS-R). Although only recently we were able to show that further improvements are needed – particularly regarding the complexity of the measurement22 – in future studies the YGTSS-R (instead of the YGTSS) should be used. Most widely used scales helpful in the diagnosis and assessment of tics are summarized in Table 1.

Table 1 Most Widely Used Scales in the Diagnosis and Assessment of Tics Adopted from Martino et al.15 (Listed in Alphabetical Order)

Characteristics of Obsessive-Compulsive Disorder in Patients with Tourette Syndrome

In TS, psychiatric comorbidities are the rule rather than the exception and occur in almost 80% of patients.1,23,24 OCB/OCD is – beside ADHD – the most common comorbid psychiatric comorbidity, particularly in adults with TS. While only a minority of patients with TS suffer from full blown OCD according to DSM (around 30%, however numbers range from 2% to 66% depending on the sample investigated1,4,5,25), a large number of patients (about 60–70%1,26) exhibit mild to moderate OCB.5

Importantly, several lines of evidence suggest that tics and OCD share a common pathophysiology.5,27 Both conditions have familial nature, but while OCB/OCD is found more frequently in females,28 tics are far more common (3–4:1) in males.29 Interestingly, genetic studies indicate that OCB/OCD and TS share a common genetical background.30–32 Como et al33 even suggested that OCB is an alternative expression of the TS phenotype, more commonly affecting female gene carriers. This presumed overlap is also reflected in the clinical manifestation making differentiation between tics and OCD-derived symptoms sometimes very challenging.

When comparing pure OCB/OCD in the absence of tics with comorbid OCB/OCD in the context of TS, a number of differences emerge. Leckman et al34 conducted a cross-sectional study aimed to investigate tic-related and non-tic-related OCD. They investigated 177 patients with OCD, of whom 56 had tic-related OCD. Patients with tic-related OCD more often suffered from obsessions with aggressive, religious, and sexual thoughts as well as compulsions with checking, counting, ordering, touching, and hoarding behaviors compared to those with pure OCD (without tics). Surprisingly, these two groups did not differ regarding the presence of “just right” phenomena. George et al35 prospectively assessed OCD in 10 patients with pure OCD compared to 15 patients with TS and comorbid OCD using the Yale–Brown Obsessive Compulsive Scale (Y-BOCS), the Leyton Obsessional Inventory (LOI) as well as a questionnaire targeting to differentiate between the two disorders. They found that patients with TS plus OCD demonstrated significantly more violent, sexual and symmetrical obsessions and more touching, counting, and self-injurious compulsions. On the contrary, patients with pure OCD suffered more often from obsessive thoughts related to dirt and germs, and – as a consequence of these – more cleaning compulsions. Interestingly, patients with TS-related OCD felt that their compulsions arouse spontaneously, while patients with pure OCD reported that their compulsions are preceded by cognitions.

Alsbrook et al36 conducted a factor analysis of “tic symptoms” in 85 patients with TS. Four significant clinical clusters were identified: (1) aggressive phenomena (eg, kicking, temper fits, argumentativeness), (2) purely motor and phonic tic symptoms, (3) compulsive phenomena (eg, touching of others or objects, repetitive speech, throat clearing), and (4) tapping and absence of grunting. Eapen et al37 reported about clinical features and associated psychopathology in 91 patients with TS and found that OCB was positively correlated with the presence of ADHD and SIB. With regard to psychopathology in adults, principal component factor analysis yielded two factors, “obsessionality” and “anxiety/depression”, which accounted for 72% of the variance. Mathews et al38 presented results of the study examining clinical and genetic data of 133 individuals with TS in the intent to identify clinical/genetic clusters. Using cluster analysis, they identified two distinct groups, those with predominantly simple tics (cluster 1) and those with multiple complex tics (cluster 2). Membership in cluster 2 was correlated with increased tic severity, global impairment, medication treatment, and presence of comorbid OCB and with family history of tics, lower verbal IQ, earlier age of onset, and comorbid OCD and ADHD in the sample of Ashkenazi Jews. Another study trying to tackle the topic of diverse clinical phenotypes in TS was published by Robertson and Cavanna39 who carried out a principal component factor analytic study in 69 patients with TS. The authors identified three significant factors, accounting for approximately 42% of the symptomatic variance: Factor 1: predominantly “pure tics”, Factor 2: predominantly “ADHD and aggressive behaviors”, and Factor 3: predominantly “depression-anxiety-OCB and SIB”. Different kinds of tics occurred in all three factors. Only frowning/raising eyebrows and sniffing/smelling loaded significantly on Factors 1 and 3. In 2010, the same group conducted a follow-up study in a larger sample of 639 patients with TS.40 Using a principal component factor analysis, again three factors were identified: (1) complex motor tics and echo-paliphenomena; (2) ADHD plus aggressive behaviors; and (3) complex vocal tics and coprophenomena. OCB was significantly associated with the first two factors. The three factors accounted for 48.5% of the total symptomatic variance. Similarly, Huisman van Dijk41 reported about a relationship between tics, OCB, ADHD and autism symptoms. Their analysis revealed a five-factor structure including (1) tic/aggression/symmetry, (2) OCB/compulsive tics especially related to numbers and patterns, (3) ADHD symptoms, (4) autism symptoms; and (5) hoarding/inattention symptoms.

Terminology Used to Describe Phenomena Related to Obsessive-Compulsive Behaviors in Tourette Syndrome

Various terminologies are used to describe OCB/OCD related phenomena in TS including OCB, obsessive-compulsive symptoms (OCS), OCD, “just right” phenomena, “not just right experiences” (NJRE), repetitive behaviors, compulsive tics, and cognitive tics. It is important to realize that these symptoms belong to the same spectrum, largely overlap and in part are used synonymously. While OCD is clearly defined – according to DSM-5 as outlined above, for all other term – although often used – clear and generally accepted definitions are missing. In general, a patient is diagnosed with OCB, if obsessions and/or compulsions are only of mild severity and do not fulfil diagnostic criteria for OCD.

In contrast, NJRE specifically involve sensations of “incompleteness” rather than the need to “avoid harm” as typical seen in other OCD symptoms. “Just right” experiences are related to discomfort or tension rather than anxiety.42 Interestingly, they have been reported to proceed or accompany both tics and compulsions.7 Furthermore, Leckman et al8 suggested that premonitory urges (PUs)43 that typical proceed tics in TS show similarities with “just right” sensations. Most typically, PUs are described as an itch, discomfort or pressure. It is believed that PUs make patients execute tics in response to urges. Similarly, Coles et al44 described experiences of “not just-right” in patients with pure OCD defined as a feeling of “incompleteness”, if a specific mental or physical act is somehow performed incorrectly. Accordingly, da Silva Prado et al42 stated that we are still lacking a consensus regarding these different terminologies. Instead of using the term, PU, “just-right” and NJRE, alternatively the umbrella term “sensory phenomena” has been proposed.45

Compared to OCB/OCD, the term “repetitive behaviors” describes a far wider spectrum of symptoms including both impulsions, compulsions, stereotypies and even tics. It is used in the context of a variety of different neuropsychiatric disorders such as autism spectrum disorder (ASD), TS, OCB/OCD, schizophrenia, dementia, epilepsy, and eating disorders. In contrast, the terms “compulsive tics” and “cognitive tics” are used only in context of TS and other tic disorders. Compulsive tics are defined as “repetitive movements performed according to rules (ie, ritualistic) in response to an obsession or to reduce tension”.46 They are believed to represent a specific type of complex tics that share characteristics of both tics and compulsions. In contrast, cognitive tics are defined as mental acts that bear common characteristics with tics and obsessions.47 In clinical practice, both terms compulsive and cognitive tics are used only rarely, presumably because of the not clearly defined underlying concepts. Subsequently, we discuss each of these phenomena in more detail. Finally, also SIB in TS should be differentiated as a part of the spectrum on the verge between tics and OCB/OCD as previous studies have demonstrated that autoaggression in TS is mainly associated with tics or OCD spectrum.48,49

“Just Right” Phenomena: NJRE

The term “just right” has been introduced for the first time in the context of OCD by Janet in 1903 in his work “Les Obsessions et La Psychasthe“ describing the following phenomenon: “The patients feel that actions they perform are incompletely achieved, or that they do not produce the sought for satisfaction”.50 In 1994, Leckman et al8 were the first, who used the term of “just right” sensations in the context of TS. Today, it is generally accepted that “just right” phenomena represent the most common OCB in patients with TS. They are defined as the execution of an action in a certain way in order to achieve internal relief.8,51 In 2013, Neal and Cavanna51 alternatively introduced the term “not just right experience” (NJRE) in TS research after this term has been used since 1992 in studies related to OCD.52 Although semantically more accurately compared to the term “just right”, the synonym NJRE is less commonly used in TS research.

Leckman et al8 carried out a cross-sectional study in 134 subjects aged 9 to 71 to evaluate “just right” phenomena in patients with tic disorders. While 81% of patients with TS and comorbid OCD reported on a need to perform compulsions until a feeling of “just right” is achieved, only 56% of those with TS and comorbid OCB experienced such as feeling. Most of the patients described these sensations as a visual or tactile feature of the compulsion. Because of this overlap, the authors speculated that brain regions involved in sensorimotor processing are also involved in the pathophysiology of tics. In a large single-center study including 1032 patients with tic disorders, 10% and 62% were diagnosed with OCD and OCB, respectively (based on a structured clinical interview) with NJREs being the most common symptom followed by checking, ordering, washing, and counting.1

Neal and Cavanna51 for the first time used the “Not Just Right Experiences Questionnaire-Revised” (NJRE-QR) to systematically investigate NJRE in 71 adults with TS. This scale was originally introduced by Coles et al53 to assess NJREs in patients with OCD. They found that 80% of patients with TS report at least one NJRE. However, patients with comorbid OCB/OCD experienced significantly more NJREs compared to those without. The strongest correlation was found between NJRE-QR scores and self-report measures of compulsivity. The authors’ final conclusion was that NJREs are presumably more related to OCD than to tics. This hypothesis is in line with results of studies in pure OCD reporting an incidence of 95% of NJREs in OCD patients.44,54,55

Taken together, the clinical spectrum of OCB in patients with TS is broad. In any case, it is vital to actively inquire about OCB-related phenomena in order not to overlook these symptoms, particularly, because patients often do not report about it spontaneously. This procedure is of clinical importance, since “full blown” OCD often impairs patients’ quality of life to a greater extent than the tics. Compared to pure OCD, patients with TS and comorbid OCB/OCD more frequently suffer from “just right” phenomena, which is the most typical OCB in TS. More precisely, we suggest to use the term NJRE.

Repetitive Behaviors Related to Tourette Syndrome

Cath et al56 investigated the relationship between types and severity of repetitive behaviors in patients with TS plus OCD and pure OCD. They enrolled 14 subjects with TS and comorbid OCD, 18 with “TS only” (without comorbidities), 21 with pure OCD, and 29 healthy controls. Across the study groups, obsessions were more severe than impulsive behaviors and compulsions. Compared to pure OCD, patients with TS and comorbid OCD reported more “Tourette-related” impulsions such as mental play, echophenomena, impulsive, and SIB, but less obsessions and particular types of compulsions including washing. The authors concluded that patients with TS and comorbid OCD are phenomenologically more similar to TS than to pure OCD. Banaschewski et al57 analyzed data of a worldwide database on TS including 4833 individuals. OCB co-occurring with TS was associated with impulsive and aggressive behavior as well as with depression and anxiety. Worbe et al58 studied 166 patients with TS aged 15–68 to investigate whether repetitive behaviors represent a manifestation of OCD or belong to the tic spectrum. In their cohort, they found repetitive behaviors in 65% of patients. Based on clinical phenomenology, they identified three types of repetitive behaviors: a “tic-like” type (in 24% of patients) presenting with symptoms such as touching, counting, “just right”, and symmetry; an “OCD-like” type (in 20% of patients), manifesting with repetitive behaviors such as washing and checking rituals; and finally, a “mixed group” suffering from both “tic-like” and “OCD-like” types of repetitive behaviors (in 13% of patients). Only 6% of patients could not be classified in any of these groups. The authors concluded that in TS, different types of repetitive behaviors can be distinguished: “tic-like” behaviors, which seem to be an integral part of TS and “OCD-like” behaviors correlating with a higher score of complex tics and more frequent treatment with antipsychotics and selective serotonin reuptake inhibitors (SSRIs) as well as worse socio-professional functioning.

Eddy and Cavanna59 reviewed the literature in order to explore the nature of TS and OCD in more detail. They suggest that both disorders represent a continuum with contamination worries being more indicative for “full-blown” OCD, while repetitive behaviors are more linked to echophenomena, ordering, symmetry, and counting as typically seen in TS. Based on their research it is less clear, whether there is a difference between OCD- and TS- specific checking behaviours. They also postulate that patients with OCD are mainly focused on avoiding harm as much as possible, while in patients with TS repetitive behaviors such as self-defeat and SIB (eg, touching very hot or sharp objects) or socially dangerous acts (ie, non-obscene socially inappropriate symptoms, NOSI) are more characteristic.

All in all, distinction between “tic-like” and “OCD-like” repetitive behaviors can be very challenging. However, “tic-like” repetitive behaviors are usually preceded by premonitory urges, are ego-syntonic, and are not accompanied by intrusive thoughts, while “OCD-like” repetitive behaviors are typically anxiety-driven, are accompanied by obsessions, and are ego-dystonic.

Compulsive Tics

According to Palumbo and Kurlan,46 compulsive tics represent repetitive behaviors in patients with TS that comprise features of both compulsions and complex tics making it impossible to classify the particular symptom either as a tic or as a compulsion. Alternatively to the term compulsive tics, they suggested the term “compultics”. Thus, compulsive tics are defined as repetitive movements performed according to rules, in response to an obsession, or to reduce tension, for example touching a door a certain number of times. The author highlight that compulsive tics most typically have to be performed according to specific rules, ritualistic behaviors, in a certain number of times, in a certain order or at a certain time of day (eg, bedtime rituals).

To distinguish tics from compulsions, a thorough clinical interview may be helpful: While compulsions aim at neutralizing an anxiety-driven worry, compulsive tics are not executed with the aim of anxiety reduction. Instead, they help to neutralize the feeling of sensory discomfort until a “just right” feeling is achieved or a “not just right feeling” is diminished. Whilst tics usually start at age of 5–7 and tend to exacerbate in the adolescence and decrease during adulthood, OCD initiates at the age of 10–12 and patients often experience symptom deterioration while getting older.60

Cognitive Tics

Some researchers postulate the existence of so-called “cognitive tics” or “mental tics” (both terms are used synonymously), a symptom resembling obsessions.47,61 In 2005, O’Connor62 first suggested the presence of cognitive tics. In his article, he defined cognitive tics as thoughts, phrases, urges, songs, words, and scenes that intrude into consciousness, are difficult to remove, and consecutively cause irritation to the person. Until today, it is a matter of discussion, whether this is a meaningful concept as by definition tics are classified as motor or vocal phenomena. However, obsessions are defined as coherent doubts or images about aversive events or thoughts, while cognitive tics are neutral or pleasant or even stimulating. Accordingly, obsessions are part of the OCB/OCD spectrum and – in the patients’ mind – are linked to bad consequences. In contrast, cognitive/mental tics are isolated sequences unrelated to any consequences.

Alternatively, cognitive tics could be interpreted as a part of a much broader spectrum of intrusive thoughts defined as thoughts, images or impulses that (1) interrupt an ongoing activity, (2) are of internal attribution, and (3) are difficult to control.63 Based on this concept, the authors suggest that intrusive thought and cognitive tics share a number of common characteristics: (1) they are generally conceptualized as unwanted, (2) are hardly ever considered a one-time occurrence, but rather refer to thoughts, images, or impulses that have the tendency to repeat themselves, and (3) they have intrusive nature, which means that they interrupt regular activity.

The construct of cognitive tics is another example that illustrates the overlap of tics and obsessions and the difficulties to differentiate one from the other. In patients reporting impairing cognitive tics, treatment-specific response – to either (selective) serotonin-reuptake inhibitors ((S)SRI) or antipsychotics – may facilitate the final diagnosis of either a tic-related or an OCD-related symptom. Common and distinguishing features of tics and obsessions/compulsions are summarized in Table 2.

Table 2 Similarities and Disparities Between Tics and Compulsions/Obsessions

Self-Injurious Behavior (SIB)

Another phenomenon on the frontier between tics and compulsions is SIB found in about 40% of patients with TS.1,48,49,64,65 SIB is defined as auto-aggressive behavior directed against oneself. It is carried out although its senselessness and the risk of injury are recognized. SIB either consists merely of an urge to injure oneself against one’s will or are accompanied by actual damage to one’s own body against one’s will. Thus, injuries caused by auto-aggressive actions are not accidental and SIB is not accompanied by suicidal intent. Until today, it is unclear whether SIB is more related to tics or to OCD or represents an independent phenomenon. From previous studies it is suggested that SIB is associated with both complex motor tics and coprophenomena, but also different psychiatric comorbidities.1,48,49 In a recent study, our group66 developed a specific diagnostic instrument for rating complexity and severity of SIB in patients with TS, the Self-injurious Behaviour Scale (SIBS). In a large sample, 103 of 123 adult patients (84%) reported SIB. Remarkably, SIBS scores correlated with tic severity as assessed by the Adult Tic Questionnaire (ATQ), but not with the severity of OCD or any other psychiatric comorbidity (unpublished data). From these results therefore it is suggested that SIB represents a specific type of tic rather than an OCD-related phenomenon.

SIB must be differentiated from severe and/or complex motor tics that cause physical impairment (eg, because of the intensity or high frequency of the tics). In addition, harm caused by OCD with excessive washing and grooming must be differentiated. Finally, also impulsive behavior related to ADHD and rage attacks may result in physical injury that must be differentiated from SIB.48

Scales Used for the Diagnosis and Assessment of Obsessive-Compulsive Disorder

According to ESSTS guidelines,9 it is recommended to actively inquire about psychiatric comorbidities in every patient with TS as type and severity of clinical symptoms determine the therapeutic approach. Although in any case the diagnostic interview should cover the whole spectrum of common comorbid disorders, it should be oriented differently depending on the patient’s age. While in children the primary focus should be on ADHD followed by ASD, oppositional defiant disorder (ODD), learning disorders, anxiety disorders, and rage attacks, in adults predominant comorbidities are OCB/OCD and mood disorders followed by anxiety disorders, ADHD, rage attacks, and SIB.

For diagnosing comorbid OCB/OCD we recommend to use DSM-5 criteria, but also structured interviews can be used, particularly, the Mini International Neuropsychiatric Interview,67 the Structured Clinical Interview for DSM Disorders (SCID)68 in adults, the Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI KID),69 and the Schedule for Affective Disorders and Schizophrenia for School Aged Children-Present and Lifetime Version (K-SADS-PL)70 for children, respectively. When it comes to further evaluation of OCB/OCD, the best investigated, most widely used, and, therefore, recommended scale is the Y-BOCS71 and equivalently, for children, the Children’s Yale–Brown Obsessive Compulsive Scale (CY-BOCS).72 Y-BOCS and CY-BOCS are 10-item, clinician-administered scales created to rate symptom severity, but not to establish a diagnosis. They contain symptom checklists and provide five rating dimensions for both obsessions and compulsions: time spent or occupied, interference with functioning or relationships, degree of distress, resistance, and control (ie, success in resistance). Each item is rated from 0, meaning “no symptoms”, to 4, “extreme symptoms”. As the (C)Y-BOCS is considered the gold standard for the assessment of OCB/OCD, we strongly encourage to use this scale in clinical practice. However, a number of other validated and well-established rating scales is available including the Obsessive-Compulsive Inventory (OCI)73 and the OCI-Child Version,74 the LOI75 and the LOI – Child Version Survey,76 and the Children’s Obsessional Compulsive Inventory (CHOCI).77 Scales helpful in the diagnosis and assessment of OCB/OCD in patients with TS are summarized in Table 3.

Table 3 Most Often Used Scales in the Diagnosis and Assessment of OCD (Listed in Alphabetical Order)

While in the context of clinical studies, use of well-established standardized assessments is of utmost importance, in daily clinical routine practice, a structured interview represents the gold standard to capture the whole clinical symptom spectrum. Up to now, none of the available measurements can be used to unequivocally classify phenomena on the borderline between tics and OCB/OCD as one of these. Unfortunately, “tic-like” as well as “OCD-like” repetitive behaviors are included in rating scales for both tics and OCB/OCD including the gold standard measurements. For example, SIB is mentioned in the symptom lists of both YGTSS and Y-BOCS. In other words, up to now differentiations between one and the other solely relies on clinical judgement. This in turn underlines the importance of centers of excellence for TS with extensive clinical experience. For all clinicians treating patients with TS, it is of importance to know that tics and OCB/OCD often co-occur. Not quite rarely, patients themselves may be able to assist disentangling “tic-like” from “OCD-like” repetitive behaviors, when comparing the phenomenon at issue to unequivocal tics (such as eye blinking) or unequivocal OCB/OCD (such as checking). Finally, treatment-specific response to either SSRI or antipsychotics may help to make the final diagnosis.

Treatment of Tics and Comorbid Obsessive-Compulsive Disorder in Patients with Tourette Syndrome

It is important to bear in mind that comorbidities – and in particular comorbid OCD – often cause greater impairment in patients’ quality of life than tics.78–81 In general, treatment of OCB/OCD in patients with coexisting tics/TS is based on the same premises as the treatment of patients with (pure) OCD without tics. Unfortunately, until today there is no treatment known that improves both tics and OCB/OCD. Regarding behavioral therapy (BT), for the treatment of OCB/OCD, Exposure and Response Prevention (ERP) is preferred,82,83 while in the therapy of tics Cognitive Behavioral Intervention for Tics (CBIT) is recommended.84,85 Alternatively, for OCB/OCD pharmacotherapy with SSRI can be initiated,86–89 while first choice treatment for tics are antipsychotics such as aripiprazole. Since ERP and pharmacotherapy with SSRI have similar efficacy on OCD,90 BT should be recommended as first-line treatment. If monotherapy with either ERP or pharmacotherapy is insufficient, combined treatment should be offered. If OCB/OCD responds partially to pharmacotherapy with SSRI, alternatively, augmentation with antipsychotics such as aripiprazole can be taken into consideration.88,91 If all these interventions fail to significantly improve OCD, gradual dose up-titration of the SSRI should be considered until intolerable adverse events occur. In refractory patients experimental treatments including cannabis-based medicines92–99 and finally surgical treatment with deep brain stimulation100 may be considered.


All in all, OCB and OCD are one of the most frequent comorbid psychiatric symptoms co-occurring in patients with primary tic disorders including TS. Since patients often do not spontaneously report on these symptoms – either because they are unaware of the relationship to TS or they are ashamed of their behaviors and thoughts – it is recommended to actively ask all patients about obsessions and compulsions not only at first consultation, but also at follow-up visits. Depending on the clinical context – as well as in clinical studies – it may be helpful to assess severity of OCB/OCD using the (C)Y-BOCS. By far the most frequent and most typical obsessions in patients with TS are “just right” phenomena, which more accurately should be named NJER, followed by compulsions with violent and sexual thoughts as well as symmetrical obsessions, touching, and counting. Differential diagnosis of OCB/OCD in TS includes tics, especially complex motor tics performed in the sequence, SIB, and mental phenomena on the frontiers between tics and obsessions, called cognitive tics. In patients with impairing OCB/OCD treatment with either ERP or SSRI should be offered depending on the preference of the patient.

Mental health awareness cannot be confined to the month of May

I’m plagued by a crippling case of generalized anxiety, obsessive-compulsive disorder, addiction, and an abyssal, recursive case of depression. I also never talk about this publicly. My illness, it seems, is the desolate burden of me and my psychiatrist alone. Not that any of this makes me special or unique — it’s been my general attitude that if my mental ailments are all I have to complain about, then I’m doing something right. That being said, this burden can be a grim and solipsistic one. Moreover, the fact that tens of millions of people are affected by mental illness year after year, with cases spiking and no real causation being addressed, it’s a plight we, as a society, ought to concern ourselves with on a more rigorous, consistent basis. 

We all share in the gauntlet of the human psychic condition; playing dice with fate, seeing how we’ll react to the stimuli and phenomena of social and economic life. And nowadays, more often than not, such a game concludes in at least some degree of mental illness. According to The National Institute of Mental Health, an estimated 31.1% of U.S. adults experience an anxiety disorder at some point in their lives and an estimated 11 million U.S. adults experienced a severe depressive episode in the year the study was released, with 35% of that group not receiving treatment for their ailment. Moreover, 4.4% of U.S. adults experience bipolar disorder at some point in their lives. Equally critical to consider, according to the Centers for Disease Control and Prevention, in 2019, 70,630 drug overdose deaths occurred.

What’s more, from 2018 to 2019, the U.S. saw a 67.9% increase in synthetic opioid-related overdose deaths — a figure that, for me, isn’t just another number. I’ve personally experienced the deaths of nine of my friends from drug-related overdoses and, sadly, there are countless others who I’ve seen pass along the way. Furthermore, when the aforementioned statistics are aggregated — anxiety, bipolar and depression included — such a figure accounts for an inordinate swath of the population. In other words, there’s an epidemic of Bubonic proportion unfolding like soundless fallout right before our eyes. And, save the studies, gradual destigmatization and psychiatric care, not much is being done to curb or alter this trend. From my perspective, it’s only getting worse.

“The depressed person is in terrible and unceasing emotional pain,” author David Foster Wallace wrote, “and the impossibility of sharing or articulating this pain is itself a component of this pain and a contributing factor in its essential horror.” What may very well come across as some pithy Twitter quote about depression, is in fact a core insight into individuals suffering from mental illness. Assuredly, the “impossibility of sharing or articulating” the anguish of the experience of mental illness is the crux of suffering, as Wallace notes. And in the context of our social rituals and values, it is the crux of our societal ills too. 

See, we are living in what the social theorist Byung-Chul Han has termed as the “Burnout Society.” According to Han, we are a culture that resists negative interpretations of the self and our world, leading to an ethics of achievement, positivity and activity. In another sense, we are constantly being told that we can achieve anything, and therefore, we have to achieve something. This persistent pressure to “do,” alongside the achievements of others around us, logically leads to tiredness, exhaustion and burnout — to illness. “Tiredness of this kind proves violent,” Han wrote in his book “Burnout Society,” “because it destroys all that is common or shared, all proximity, and even language itself.”

We cannot effectively share or articulate our suffering, as Wallace noted. We must instead “hustle,” “never quit,” “believe in ourselves,” “dream big,” “start something,” ad infinitum. Per the parameters of our societal norms — visible through social media outlets such as Instagram, the echo chamber of positivity and influencer-driven virtue — individuals suffering from mental illness must cloak their condition with a thin shroud of placid social niceties. It’s hard, if not impossible, to articulate the experience of mental illness via the coordinates of these social rituals and values we have constructed. In this sense, mental health awareness is not simply an individualistic, clinical concern. It is a societal concern, and our awareness of it and our collective efforts to address it ought to persist past the month of May.

The point of delineating causation as opposed to the normal pharmacological or pop-psychology narratives is not to discredit or argue against them — I take medication and undergo psychotherapy myself. The point is to explain that there is much more to it than popping a few pills and talking about your feelings. A tangible degree of social consciousness is required if we are to truly start saving lives. Mental health awareness is a massive societal concern. So keep us in mind — because we would, but it’s a mess for us up there.

6 Ways anxiety disorders develop and how to cope with them

Anxiety disorder is a type of mental health disorder that is characterised by excess fear, worry, or anxiety. This disorder includes panic attacks, obsessive-compulsive disorder, and post-traumatic stress disorder. The symptoms of this disorder are excess stress, constant worrying, and fear, etc. There are many ways in which anxiety disorders develop. So, psychologist, Dr. Malini Saba, Founder and Chairman, Saba Group talks about the red flags that can trigger anxiety disorder and how to cope with it.

Lack of Quality Sleep

A lot has been said about getting 6-8 hours of sound sleep for a healthy mind and body. While not many will concur with this, however, sleep and mental health are closely interlinked. Sleep deprivation can severely impact one’s psychological state and mental health, leading to anxiety issues. One should keep an eye on their sleeping pattern, and seek help if they face insomnia, frequent nightmares, etc. Catching these early warnings can help eliminate the chances of developing anxiety.

Mulling over things that are beyond the control

In the current scenario, with the pandemic raging on, all of us are doing everything in our power to keep ourselves and our loved ones safe from the wrath of Covid-19. However, in some cases, in spite of the best efforts, the situation can deteriorate and can cause anxiety. In such times, it is better to focus on the situation at hand instead of dwelling on the negatives. This will help create a positive attitude and can lessen the chances of developing anxiety.

Alcohol abuse

Unwinding with a glass of wine or beer after a long day may sound tempting to many, however, alcohol dependence and subsequent abuse can be the reason for alcohol-induced anxiety. Also using alcohol as a crutch to overcome social anxiety, in reality, can worsen the symptoms. Since alcohol hampers the normal functioning of an individual, long-term abuse can induce panic attacks and even lead to PTSD.  The best way to deal with alcohol-induced anxiety is to be mindful of your consumption and reach out for support from family and friends to tackle these difficult times.


One of the biggest contributors to the development of anxiety disorder is stress. In our day-to-day life, all of us endure stress. While we can’t completely eliminate it, however, it is necessary that we do not fall victim to it. Stress and anxiety go hand in hand where one heightens the symptoms of the other. If you suddenly have any of the physical symptoms ranging from severe headaches to unexplained spells of dizziness, it is time to take a breather and focus on calming your mind and relaxing your body. Breathing exercises are the best ways to do this.

Zero self-love

Treating your mind and body with a day of relaxation can do wonders and can also reduce the chances of developing any anxiety disorders. So, take a day off and indulge yourself in activities you enjoy and refresh your mind.

Side effects of medication

Every medication has side effects and it’s best to avoid them until absolute necessity. Few medications also contribute to the development of stress and can even induce panic-like symptoms. In such cases, it’s best to consult your doctor and consider changing the medication.

Also Read: Can breathing techniques improve your mental health? An expert opines

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Perfectionistic cognitions appear to play a key role in clinical anxiety

A new study found that perfectionist thinking patterns contributed to posttraumatic stress disorder (PTSD) and generalized anxiety disorder (GAD) symptoms, over and above several known control variables. The findings were published in Cognitive Behaviour Therapy.

Perfectionism involves a desire to perform to the highest standards without allowing room for failure. People with perfectionist beliefs tend to be overly self-critical and put pressure on themselves to perform flawlessly at all times. While perfectionism is often seen as a favorable trait, the attribute has been linked to numerous anxiety disorders such as obsessive compulsive disorder (OCD) and social anxiety disorder (SAD).

Researchers have recently begun exploring the thought patterns that characterize perfectionism — called perfectionist cognitions (PC). As study author Jeremy Tyler and his team say, perfectionist cognitions include expectations about achieving perfection such as, “I can’t stand to make mistakes.” These cognitions have been linked to dysfunctional mental health symptoms like obsessions, distress, and anxiety. However, these associations have yet to be explored among a clinical population.

In a new study, Tyler and his colleagues wanted to extend the current findings by exploring perfectionist thought patterns among a sample of patients with diagnosed anxiety or anxiety-related disorders.

A total of 356 adults between the ages of 18 and 69 participated in the study. The most common primary diagnoses were OCD, SAD, and GAD. More than half (52%) of respondents had more than one mental health disorder diagnosis.

In a self-report survey, the subjects completed the Perfectionism Cognitions Inventory (PCI), which included a list of 25 perfectionist cognitions (e.g., “No matter how much I do, it’s never enough.”). Subjects were asked to rate how often they had experienced each of these thoughts in the last week. They also completed assessments of symptoms of GAD, OCD, SAD, depression, panic disorder, and PTSD. Finally, they completed assessments of emotion regulation difficulties and anxiety sensitivity.

The researchers found that perfectionist cognitions were positively linked to anxiety disorder symptoms across a range of diagnoses. More importantly, scores on the PCI still accounted for a significant percentage of variance in GAD symptoms and PTSD symptoms after controlling for symptoms of depression, anxiety sensitivity, and difficulties in emotion regulation — three factors that are known to relate to both perfectionist thinking, anxiety, and PTSD.

“These findings imply that treatment-seeking individuals experiencing more frequent thoughts about striving towards perfection were more likely to endorse more severe symptoms of GAD and PTSD beyond the contribution of anxiety sensitivity, deficits in emotion regulation, or depressive symptoms,” Tyler and colleagues report.

The authors discuss a few reasons why perfectionist cognitions might lead to increased anxiety. One possibility is that perfectionist thought patterns increase vulnerability to anxiety by encouraging a hyper-focus on perfection and acute awareness of failure that then leads to negative emotions like anxiety. The researchers say their findings suggest this pathway may be even more likely to occur among people with a GAD or PTSD diagnosis.

Tyler and team say their findings provide a basis for future studies regarding the role of PC in anxiety-related disorders. The findings also suggest that the treatment of anxiety disorders might benefit from a focus on addressing the presence of perfectionist cognitions.

The study, “The unique contribution of perfectionistic cognitions to anxiety disorder symptoms in a treatment-seeking sample”, was authored by Jeremy Tyler, Wenting Mu, Jesse McCann, Gina Belli, and Anu Asnaani.

Anxiety: Physical symptoms and how to cope with them

Although anxiety disorders come under the umbrella of mental health conditions, they can also cause physical reactions.

In addition to distress, fear, and worry, a person may have physical symptoms of anxiety, including:

Panic attacks can occur suddenly. If a person experiences a panic attack, they may feel that they are in extreme danger or are losing control.

People can have strong physical reactions during a panic attack, and they may even feel as though they are having a heart attack.

Some symptoms of a panic attack may include:

  • chest pain
  • chills
  • difficulty breathing
  • problems swallowing, or a feeling of choking
  • excessive sweating
  • a racing heart rate
  • feeling faint and nauseous
  • feeling that death is imminent
  • hot flashes
  • hyperventilation
  • numbness or tingling in the fingers, arms, or toes
  • shaking
  • stomach pain
  • a feeling of cold in the hands and feet
  • feeling detached from the body
  • dizziness or lightheadedness
  • blurry vision

Learn more about the differences between anxiety and panic attacks here.

Why the body responds to anxiety

Stressful life events can trigger panic attacks. However, panic attacks do not always have an obvious cause.

The physical symptoms of panic attacks are due to the body’s fight-or-flight response, which generates fear and anxiety.

During the fight-or-flight response, an individual responds to authentic and unreal danger in the same way and with the same physiological reactions. For example, their heart and breathing rates increase, they have a surge of adrenaline, and their senses become hyperalert.

A person’s body responds in this way because it is preparing to either fight the threat or run away from it.

The increase in blood flow prepares the muscles to flee from danger and allows the brain to focus and make quick decisions. The rapid breathing provides the body with more oxygen, ready to escape.

However, these things may cause the individual to feel as though they cannot get enough air, which may result in further feelings of panic.

The long-term effects

Anxiety disorders can cause people to avoid situations that they know trigger negative emotions. They may feel ashamed that they cannot live their lives as everyone else does. In turn, this may lead to increased social isolation and further withdrawal.

When this happens, a person may enter a cycle of living in fear of fear, meaning that the fear of a panic attack causes them to have more panic attacks.

If someone has chronic anxiety, they are always on high alert. This may negatively affect their cardiovascular, digestive, immune, and respiratory health.

No, OCD in a pandemic doesn’t necessarily get worse with all that extra hand washing

At the beginning of the COVID-19 pandemic, we were concerned infection control measures such as extra hand washing and social distancing might compound the distress of people living with obsessive-compulsive disorder (OCD).

Early anecdotal evidence and case studies reported an apparent increase in OCD relapse rates and symptom severity.

But a year on, we’re learning this is not necessarily the case, and research is giving us a more nuanced understanding of what it’s like to have OCD during a pandemic.

Read more:
Hoarding, stockpiling, panic buying: What’s normal behavior in an abnormal time?

What is OCD?

OCD is a common and disabling condition, affecting roughly 1.2% of Australians.

It’s characterised by obsessions (repetitive intrusive thoughts) and compulsions (physical actions or mental rituals) that attempt to quell these preoccupations.

There are several subtypes of OCD, including:

  • contamination: characterised by obsessions and compulsions centred around washing, cleaning and concerns around personal hygiene and health

  • overresponsibility: encompassing pathological doubt, concerns over unintentional harm to others or oneself, and persistent urges to check things

  • symmetry: obsessions about things feeling “just right” (for example, uniform and/or symmetrical), resulting in ritualistic behaviours including counting and ordering

  • taboo: characterised by unwanted intrusive thoughts that are often violent, sexual or religious in nature.

Although we don’t fully understand what causes OCD, research points to abnormal activity of specific brain networks, including a network called the cortico-striatal-thalamo-cortical loop.

This network connects key emotional, cognitive and motor hubs in the brain, and it’s particularly important for higher-order cognitive tasks such as thinking flexibly.

No, people with OCD aren’t ‘quirky’

There are several prevailing stereotypes about what it means to live with OCD, such as a belief people with the disorder are just a bit quirky, overly particular, “neat freaks” or “germ-phobic”.

Such ideas are frequently promulgated in popular culture. For example, in 2018 Khloe Kardashian promoted her “KHLO-C-D” branding for an online miniseries in which she gave tips on home organisation and cleanliness. The campaign was widely criticised.

While contamination fears and an affinity for symmetry are better recognised in the community (perhaps owing to portrayals in TV and film), the “taboo” and “overresponsibility” dimensions of OCD are far less understood and are therefore subject to higher levels of stigma.

Are we all OCD now?

The global response to COVID-19 has blurred the line between pathological behaviours and adaptive health and safety measures.

Behaviours that were previously linked to psychiatric illnesses, such as repetitive washing and sanitising rituals, are now encouraged (at least to some extent) by health authorities.

While infection control directives such as social distancing and hand hygiene play an essential role in our fight against the virus, they take a psychological toll too.

The pandemic has had a profound effect on mental health due to increased stress and lifestyle changes. Indeed, scientists have recently proposed a condition called “COVID-19 stress syndrome”. Some of the symptoms significantly overlap with anxiety disorders and OCD.

While we don’t all have OCD now, it’s unquestionable our collective behaviour has changed in ways that make the distinction between “normal” and “pathological” much more complex.

In this light, the International College of Obsessive–Compulsive Spectrum Disorders has highlighted the unique challenges the pandemic poses for accurately diagnosing OCD.

Read more:
You can’t be ‘a little bit OCD’ but your everyday obsessions can help end the condition’s stigma

Living with OCD in a pandemic

Having a pre-existing mental health condition appears to be the single most influential predictor of high stress levels during COVID-19.

However, recent evidence from well-controlled studies doesn’t find compelling evidence that people with OCD have been affected by COVID-19 to a greater extent than those with other psychological conditions (such as depression or general anxiety).

One study published in January compared OCD severity in a large group before and during the pandemic. It found the stress induced by COVID-19 increased measures of mental distress across all OCD symptom dimensions (not only those directly related to a public health crisis).

The authors suggested the increase in OCD symptom severity was likely a “non-specific stress-related response”. In other words, it’s the general stress of the pandemic that has worsened OCD in some cases; not the increased focus on infection control.

A woman sitting on the couch, appears pensive or unhappy.
Having a pre-existing mental health condition is the biggest risk factor for having high stress levels during the pandemic.

Another recent study found the pandemic didn’t lessen the benefits of treatment in a large outpatient group with OCD in India.

Interestingly, the researchers from this study also found prior incomplete disease remission (cases of OCD that persisted even with treatment) and general stress were the best predictors of OCD relapse during the pandemic, rather than “COVID-specific” stress, per se.

After the pandemic

These findings don’t suggest there’s a specific vulnerability to COVID-related stress for people with OCD.

But it’s worth noting cognitive inflexibility, a symptom often seen in OCD, may make it more difficult for people with the disorder to “unlearn” temporary public health directives.

So it’s important we continue to monitor the effects of COVID-related stress on OCD and similar disorders, particularly as we slowly transition from the pandemic.

There’s much we can learn from the study of OCD during COVID-19. Most notably, it appears an “intuitive” understanding of the disorder doesn’t sufficiently capture the breadth of individual OCD experiences.

A deeper understanding of the variability of OCD presentations, and a move away from stereotyped perceptions, may encourage more people to openly discuss their own OCD experience and seek treatment.

Read more:
My skin’s dry with all this hand washing. What can I do?

Need support?

If you live in Australia, call Lifeline (13 11 14), Kids Helpline (1800 551 800) or BeyondBlue (1800 512 348). Alternatively, “OCD STOP!” is a free online program designed to help you better understand and manage OCD.

If you simply want to learn more about OCD, online resources are available at SANE Australia and Beyond Blue.

Treating the Compulsive Personality: Transforming Poison into Medicine

One summer during my analytic training, I committed myself to study, outline, and completely internalize Nancy McWilliams’s Psychoanalytic Diagnosis (1994). The idea that you could be more effective with clients by understanding their specific patterns ran contrary to the anti-diagnosis attitude at my training institute. But it appealed to my eagerness to be helpful.

Not long after I began, I recognized myself in the chapter on the obsessive-compulsive personality. While I didn’t meet the DSM-5 criteria for obsessive-compulsive personality disorder (OCPD), I certainly had my compulsive traits: perfectionism, over-working, and planning, just to name the obvious. McWilliams’ description elucidated who I could have become, had I not had a supportive family and lots of analysis to rein in those tendencies.

But this wasn’t just personal or theoretical. I recognized the collection of traits found in the personality style in my many driven, Type A, and perfectionistic clients working in law, finance, and publishing in work-crazed midtown Manhattan. And I saw the suffering it caused.

The Unrecognized Stepchild of Personality Disorders

Captivated by the subject, I eventually got involved in some online OCPD support groups. There, I read many stories of people who thought they had OCD for years before finally realizing that their entire personality was characterized by compulsive tendencies. They had known that their struggles weren’t just with specific obsessions and compulsions, but that was the only diagnosis they were aware of that was even close to describing them. And in many cases, OCD was the diagnosis a clinician had given them.

This pattern of misdiagnosis became even clearer once I began receiving comments and emails from people reading my new blog, The Healthy Compulsive Project, and my book, The Healthy Compulsive.

While OCPD is one of the most frequently occurring personality disorders of the ten listed in the DSM, it is under-recognized and probably underdiagnosed (Koutoufa Furnman, 2014). Far too often, it’s confused with OCD by both the public and clinicians. One study indicates that the lack of recognition of the condition leads to a lack of empathy for it (McIntosh Paulson, 2019). And far more people suffer from obsessive-compulsive personality traits than those who meet the full criteria.

It doesn’t help that it’s ego syntonic not just for the sufferer, but to some extent for our culture as well. Capitalism doesn’t care if you work too hard. According to psychologist and researcher Anthony Pinto (2016), there is no empirically validated gold standard treatment for OCPD. I suspect that this is a function both of our tolerance of it and of the difficulty in treating it.

What’s the Meaning of This?

As I filtered all of this through my training as a Jungian analyst, my curiosity about the underlying meaning of the disorder was piqued. Jung emphasized the importance of asking what symptoms and neuroses were for. What potentially adaptive purpose did symptoms serve in the patient’s life, or for humankind at large? Could there be meaning under something so destructive? Was there some underlying attempt to move toward individuation gone awry?

Looking up the etymology underlying the word “compulsion,” I realized that it wasn’t originally a bad thing. A compulsion is an urge that’s almost uncontrollable. A drive or force. And that’s not all bad. Many of these urges lead to creative and productive behavior. But

before I could find any possible light in the condition, I had to acknowledge how dark it could be.

The Cost of OCPD

The more I observed the world of the obsessive-compulsive personality, the more I came to see its destructive potential. A review of OCPD by Deidrich Voderholzer (2015) tells us that people who have OCPD often have other diagnoses as well, including anxiety, depression, substance-abuse, eating disorders, and hypochondriasis. OCPD amplifies these other conditions and makes them harder to treat. People with OCPD have higher than average rates of depression and suicide and score lower on a test called the Reasons for Living Inventory (Deidrich Voderholzer, 2015).

Medical expenses for people with OCPD are substantially higher than those with other conditions such as depression and anxiety. And the study indicating this only included people who had sought treatment—which excludes the many with more serious cases who don’t (Deidrich Voderholzer, 2015).

The cost for couples and families is great. People who are at the unhealthy end of the compulsive spectrum can be impossible to live with. They can become mean, bossy and critical, and their need to control often contributes to divorce. Much of the correspondence I receive is from partners of people with OCPD who are at the end of their rope, looking desperately for hope that their partner can change.

Parents with OCPD often place unreasonable demands on their children. This can interfere with developing secure attachment and may also increase the chances of a child’s developing an eating disorder.

It also causes problems in the workplace. While some compulsives are very productive, others become so perfectionistic that they can’t get anything done. Still others prevent their coworkers from getting anything done because their criticism disrupts productivity.

Similar problems happen in other organizations such as volunteer groups and religious institutions. People with compulsive tendencies often become involved in community groups, and they’re so convinced that they’re completely right, and that they should control everything, that they contribute to the deterioration of the organization, partially because others don’t want to work with them (Deidrich Voderholzer, 2015).

Just as disturbing is knowing of the many personal, community, and cultural benefits that the condition prevents when it hijacks energy that would otherwise have led to leadership, creativity, and productivity. Compulsives can be movers and shakers, but instead they often end up being blockers and disruptors.

The people who shape the world are the ones with the most determination, not the ones with the best ideas. And compulsives have lots of determination.

The Adaptive Perspective on OCPD

As I looked more deeply into the condition, I could see that the original intention beneath compulsive control is positive: compulsives are compelled to grow, lead, create, produce, protect, and repair. It seemed to me that the obsessive or compulsive personality is not fundamentally neurotic, but a set of potentially adaptive, healthy, constructive, and fulfilling characteristics that have gone into overdrive.

I’m certainly not the only one to make this observation. A dimensional perspective of personality disorders is gaining momentum (Haslam, 2003). But this viewpoint is still sorely needed for sufferers, partners, and clinicians.

Realizing that evolutionary psychology might provide an understanding of the adaptive potential of obsessive-compulsive tendencies, I contacted psychologist Steven Hertler, who has been on the front lines of thought in this area. His ideas resonated with what I had suspected about the survival benefits of obsessive-compulsive tendencies: the behavior that those genes led to made it more likely that the offspring of those with the genes would survive (Hertler, 2015). For instance, being meticulous and cautious is part of what Hertler (2015) refers to as a “slow-life strategy,” which increases the likelihood that those genes will be handed down.

Most importantly, though, a perspective which highlights the possible benefits of a compulsive personality style has significant clinical benefits. Conveying the possible advantages of this character style to clients lowers defensiveness and encourages change.

There is a wide spectrum of people with compulsive personality, with unhealthy and maladaptive on one end, and healthy and adaptive on the other end. Clients on the unhealthy end of the spectrum can be very defensive about their condition. They tend to think in black-and-white terms, good and bad, and their sense of security is dependent on believing that they are all the way on the good side. This makes it hard for them to acknowledge their condition, enter therapy, and get engaged in treatment. When they do come in, it’s usually because their partner is pressuring them, or because they have become burned-out or depressed.

If we are to help people suffering from obsessive-compulsive personality disorder, we need to find a way to get under their defenses so that they can make use of therapy. When we understand and convey that OCPD is a maladaptive version of something much more positive, we begin to forge a good working relationship.

But as therapists, we should also acknowledge that some individuals are so far to the unhealthy end of the continuum that even if they were to enter therapy, we might not be able to help them. It was important for me, at least, to be realistic, so that I didn’t set myself up to feel that I had failed if I wasn’t able to help someone.

Characteristics of the Obsessive-Compulsive Personality

The DSM-5 says that OCPD is defined by a “preoccupation with orderliness, perfectionism, and mental interpersonal control at the expense of flexibility, openness, efficiency” (American Psychiatric Association, 2013). It goes on to list eight criteria; since these criteria are readily available, I won’t list them here. But I do want to emphasize what the DSM-5 (2013) points out in the first criteria: people with OCPD are preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost. I have found this to be a defining characteristic of people on the unhealthy end of the compulsive spectrum—they’ve lost the point of their rules and efforts to control. They’ve lost their original intention, the thing they first felt compelled to do.

I remember being struck the first time I noticed this. A female client was talking about how she had berated some people for not following the rules. It struck me that she was so adamant about the rules that she had forgotten who the rules were meant to help and protect—the very people she was berating.

One goal of treatment should be to help clients recover, or uncover for the first time, the original impulse, the deeper motivation that has compelled them. [editquote:ne goal of treatment should be to help clients recover, or uncover for the first time, the original impulse, the deeper motivation that has compelled themThat original impulse could be service to others, creation of many sorts, or repairing the world. Ideally, identifying these original impulses allows the individual to fulfil them productively, rather than obsessively or repeatedly try to carry them out in distorted ways.

Four Types of Compulsives

The more I treated people with OCPD the more I came to recognize that while there were certainly significant differences amongst them, those differences seemed to fall into a few patterns. The desire for control and perfection was the same, but the strategies they used to relieve their anxiety or to prove their worth were different. Eventually I identified four primary, overlapping styles, with both adaptive and maladaptive possibilities:

  1. Leader/Authoritarian Boss or Bully
  2. Doer/Workaholic
  3. Follower/People-Pleaser
  4. Thinker/Procrastinating Obsessive Perfectionist

This helped me to recognize clients’ dominant strategy and what was needed for balance.

In Search of a Treatment Approach

According to psychologist and researcher Anthony Pinto (2016), while we have reason to believe that psychotherapy is the treatment of choice for OCPD, we don’t have a form of treatment which has been verified by research at the “gold standard” level for evidence-based treatment of OCPD. Most of the studies we do have are either not specific to OCPD or are not rigorous enough to be certain that a particular approach is effective.

I may be biased because I practice psychodynamic treatment, but it seems to me that because OCPD affects the entire personality, psychodynamic treatment will be the most effective. I say this because cognitive and behavioral treatments are most effective for very specific issues, less so for the sort of global issues that characterize OCPD.

But those of us who work psychoanalytically may need to budge a little on maintenance of the frame, disclosure, the use of goals, and our reluctance to diagnose. Just as the saying “the only way to peace is peace” goes, “the only way to flexibility is flexibility.” We need to be mindful of our own personal need to control, and a certain rigor that our training may have encouraged: we might think or feel that we are doing the “right” thing by following the rules. But in particular aspects of the work with compulsives, we may gain more through example than through analysis.

Eight Key Points

I’ve found that there are particular themes and tasks that I usually need to work through with compulsive clients over time. I don’t believe that these are unique to OCPD, but rather that they usually require more emphasis than might with other conditions. I outline these below with the suggestion that they be used in a flexible and organic way, rather than as hard and fast steps.

In each of these steps I try to enlist clients’ adaptive compulsive characteristics to foster change.

  1. Create a narrative respecting inborn characteristics. To help compulsives diminish insecurity and develop self-acceptance, I’ve found that it is important to create a narrative which distinguishes authentic, organic aspects of their personality from those which were the result of their environment. Compulsives are born with traits such as perfectionism, determination, and attention to detail. They usually like constructive projects, and this can be a joint project that nurtures the working therapeutic relationship.
  2. Identify the coping strategy they adopted. If there was a poor fit between the client and his or her parents, the child may have used their inborn tendencies, such as perfectionism, drive, or self-restraint, to find favor and to feel more secure. Most unhealthy compulsives become so when their energy and talent are hijacked and enlisted to prevent feelings of shame and insecurity, and to prove that they are worthy of respect, inclusion, and connection.
  3. Identify when their coping strategy is still used to cope with anxiety. Recognize if and how they still use that coping strategy as an adult. Most coping strategies used to ward off anxiety will diminish if the anxiety is faced head on rather than avoided with compulsions.
  4. Address underlying insecurity. Question their self-criticism and replace it with appreciation for their inherent individual strengths, rather than pathologizing or understanding them as reactive or defensive. Reframe their personality as potentially constructive. I’ve seen this perspective help many people as they participate in OCPD support groups.
  5. Help clients shift to a more “bottom-up” psychology. Nurture their capacity to identify emotions and learn from them rather than use compulsive behavior to avoid them. Help them to identify and live out the original sources of their compulsion, such as service, creation, and repair, actions that would give their lives more meaning. Help them to make choices based on how things feel rather than how they look.
  6. Identify what’s most important. Most compulsives have either lost track of what’s most important to them, or never knew. Projects and righteousness that they imagine will impress others fill the vacuum. Instead, once they can feel what they were naturally compelled to do, they can use their determination to fulfill it in a more satisfying way.
  7. Identify personality parts. Compulsives try to live in a way that is entirely based on direction from the superego, and they attempt to exclude other aspects of their personality. I have found it very helpful to have them to label the dominant voices in their head (Perfectionist, Problem Solver, Slavedriver), and to identify other personality parts that have been silenced or who operate in a stealth way. Depending on what the client is most comfortable with, we can use terms from Transactional Analysis (Parent, Adult, Child), Internal Family Systems (Exiles, Managers, Firefighters), or a Jungian/archetypal perspective (Judge, Persona, Orphan).
  8. Use the body, the present moment, and the therapeutic relationship. Compulsives rarely experience the present and usually drive their bodies as vehicles rather than nurture them. Bringing their attention to their moment-to-moment experience and using their experience of you as their therapist can help. For instance, bring their attention to tension in their body and, if possible, connect that with any feelings that they have about you. For instance, do they feel a need to comply with you, or any resentment about complying with you?

The Case of Bart


A man in his early forties, whom I will call Bart, came to see me when his wife said she could no longer tolerate his worrying and unhappiness. To his own surprise, he found himself tearing up as he described his life to me. He didn’t do that kind of thing. Ever.

Bart was handsome, fit and bright. Yet he was very self-deprecating.

He told me that he worked in finance and had done well enough to provide comfortably for his family. But his success didn’t register with him at all. He worried about what others thought of him. He feared that people would discover that he was a hoax at his job; he believed his success was accidental and that he could lose it all at any time. At this point in his career, he was just coasting and didn’t find any meaning or challenge in it.

Bart imagined that his family tolerated him only because he provided for them. During our initial consultation, he said he wasn’t feeling bad. But it was clear that he had experienced serious depression in the past, and I suspected that he was still depressed but couldn’t acknowledge it.

His wife was lively, talkative, and highly social, but their relationship was flat at best. He made it a point to say that he did not want to blame her for any of his problems or theirs as a couple. Nor did he want to assign any blame to his parents. Any problems he had were of his own making.

He admitted that he found it difficult to engage feelings. He avoided reflection, journaling, and talking. Like most compulsives, he controlled not just the outer world, but also his inner world. It was hard for him to tolerate uncertainty.

He played organized sports about four days a week, and he had great difficulty tolerating any mistakes on the field or court. He constantly monitored success and failure with a scoreboard in his head. He had quit playing golf because he got too upset when he didn’t play well.

At the end of our initial consultation, I told him that it seemed to me that while he had adapted very well to the external world, he had not adapted well to his inner world.

Achieving that would be one of the goals of our work together. I was confident that if he could put the same energy and attention that he had put into career success into his psychological well being, he would see change.

He told me that his impressions of therapy were based on media examples and that he didn’t have any idea how this worked. I told him that I was glad he was asking because we as therapists don’t always do a good job of explaining how the therapeutic process works. I agreed to be transparent about the course of our work, to share how I believed we needed to proceed, and to explain the rationale behind my suggestions. In particular, I would try to be clear about his role in the work.


His mother was depressed and a classic martyr. Masochistic, even. She seemed to enjoy her suffering. His father worked as a salesman and was willful, driven, and judgmental. He insisted on success: winning was his religion. For Bart this meant that if his behavior didn’t lead to points on the scoreboard in terms of some productivity or success, it was meaningless. His father said, “it’s good to win.” Bart extended this to “it’s terrible to lose.”

Bart internalized the strategies of both parents, and it caused a terrible conflict: he had imperatives both to lose and suffer (his mother’s masochism), and to win and achieve (his father’s need to triumph). He chose to be more like his father from his teens until he was 25; then he switched and became more like his mother. But he couldn’t let go of the feeling that he should still be winning all the time, in addition to learning, producing, and working all the time. He had lots of “shoulds.”

He had concluded that people want compliance rather than authenticity. He was raised Roman Catholic, and he’d make up things he had done wrong to have something to admit when he went to confession. He told me that he no longer believed in God, so he had to punish himself now. He felt guilty about any sort of self-assertion. He loved post-apocalyptic films because “in that setting, you don’t have to worry about being good anymore.”

Yet Bart didn’t feel that his parents or his environment had any bearing on his current struggles. So I said that the most important thing for us now was to understand how he had adapted to the situation he was raised in.

Coping Strategy

One aspect of Bart’s strategy was trying to control people by giving them what they wanted. Meeting his father’s expectations was only the beginning. Among the four types of compulsives, he was clearly a follower/people-pleaser. He tried to achieve self-acceptance through others’ opinions of him, but it didn’t work, even when he did get accolades.

Another aspect of his strategy was to not depend on others. To do so would rob him of control. It would take time for him to realize that he actually did have social needs, but that, so far, those needs had only gone into impressing others, rather than relating to them. As with many compulsives, Bart felt it was safer to seek respect than to want love.

In his martyr mindset, being a victim implied that he was good. So he often became very negative about his life to prove to himself that he was a victim. He wouldn’t complain verbally to others, but he did need to show himself, at least, how bad his life was. Later he came to realize that his depressed moods were also unconscious attempts to communicate the misery that he could not reveal directly.

He was aware that he had adopted a strategy of planning and perfecting to try to pre-empt the utter self-contempt he unleashed on himself when things didn’t go well. “But why the self-contempt?” I asked. “If I’m self-critical, it will show other people that I won’t tolerate mistakes. But it’s become habitual. I do it even when other people aren’t looking.”

Engaging Feelings

Much of our work involved learning to identify feelings and excavating different levels of feeling so that he could operate from a more “bottom-up” approach. We spoke of therapy as a gymnasium for exercising his capacity to tune into feelings. As with many compulsives, framing our work in terms of a project was helpful in engaging him. I tried to bring attention to what he was feeling in his body and to the present moment.

Most of his feelings were about “shoulds.” Desires were few and far between. Tuning in to desires was a heavy lift for him, but with time he began to be more aware of the difference between acting on fears versus acting on desires.

At times Bart felt like giving up, whatever that might mean. I recommended that he take that seriously but not literally: What is it that you really need to give up? What is the control that you would be happier without?

As he let go of self-control, anger began to surface and eclipsed his sadness and anxiety. Part of him believed that he always did the right thing, and he got angry at those who didn’t. While he was typically self-effacing, it was new for him to acknowledge that in some ways he felt superior.

But we also needed to continue to excavate even more deeply beneath his anger and judgement to see if there were yet other levels of fear or sadness. While it was scary and sad to acknowledge how much was out of his control, it was a relief not to be avoiding it.

When he first came into treatment he had imagined that therapy would remove all his uncomfortable feelings. But with time he came to realize that it was okay to have feelings—sad, anxious or angry—and that he could learn not to amplify those feelings or carry them needlessly. With time, he didn’t need to avoid them so thoroughly.

Identifying What’s Important

Even as he learned to turn his focus inward, he found it hard to articulate his goals in life, career, and therapy. He had lost track of himself and what he really wanted long ago.

Because he had little access to feeling, he was unable to find direction. He obsessed about his job and whether to change companies or even careers. He liked the idea of a new career, especially one with a new identity, but he couldn’t follow through on that. He feared losing the fantasy of what it would be like if he did change.

As he navigated his professional and personal world, I often had to ask him what was most important to him. At first this was distressing, since he had no idea who he was or what he wanted. He was always climbing mountains, but he wasn’t sure whether taking on challenges was something he felt he was supposed to do or something he wanted to do. This skill of distinguishing how something looks from how it feels has been essential to the improvement of most of the people I work with. He couldn’t tell the difference, and we kept revisiting the distinction.

In his efforts to succeed, he’d lost track of why he wanted to succeed.

Any sense of fulfillment in accomplishments was replaced by the need to achieve to prove to others and himself that he wasn’t a fraud. Over time he came to recognize that taking on challenges was fulfilling, that he genuinely enjoyed it, and that it was vital to his feeling better. But to enjoy it, he had to let go of using the challenges to prove his worth.

He had similar realizations when telling me about learning: this wasn’t just something he should do to silence his father’s demanding voice, it was something that was very satisfying. He didn’t have to do it, he wanted to do it. And that made it more pleasurable.

We explored his feelings about his marriage. He did value his marriage but was reluctant to depend on his wife: “I’d like to think that I don’t need my wife, but I do. And because I don’t want her to be too important, I don’t take in her support.” This would have made him too vulnerable and would have gone against the masochism he adopted from his mother.

It was a small revelation to him when he was recounting his weekend and noticed that spending time with his son had actually been pleasurable. It wasn’t just a “should.” Noticing this feeling of pleasure was a small window into what was most important for him. “I’ve been putting points in the wrong basket all along, thinking that making money was most important…I have to challenge the idea that piling one more dollar on the stack will make me feel better.”

He came to value more peaceful emotional states—being more present and accepting, and less regretful and judgmental.

Transference Countertransference

Coming to therapy was not comfortable for Bart, partially because he felt he wasn’t “good” at it.

I remembered that he had quit playing golf because he wasn’t good at it and wondered to myself if the same could happen with therapy. Still, his ability to speak to me directly about his discomfort was a success. Doing so served as a sort of psychoanalytic exposure therapy, staring down his deep fear of being real and of being known, with the added advantages of eventually understanding the causes and functions of those fears.

He once asked whether therapy was like confession. I explored what it was like in that regard for him and reminded him that when he was young he would make up sins to take to confession. Would he need to do that here? He didn’t think so.

He admitted that he wanted to learn the language of psychotherapy to please me. “Sometimes I tell you what I think you want to hear. I never lie to you, but I do try to figure out what you want.” He felt pressure in the silence to figure out what he was supposed to say. We explored this as a good example of his strategy.

“I’m afraid you think I’m a dick,” he said. “I’ve got so much, what’s my problem? Why am I complaining? You must think I’m just indulging here.” Was this feeling unique to our situation, or was this actually typical of how he felt with most people? He acknowledged that he never felt that it was okay to feel even tolerably accepting of himself, much less feel really good. That would be indulgent and arrogant. And it would invite humiliation.

He had imagined that I would give him a thumbs up at some point, certify him as mentally healthy, and send him on his way. We used this as an opportunity to distinguish what was more important: what I thought about him or how he felt about himself.

Allowing me to know him, and questioning how he imagined I saw him, was a step in the direction of being more open with people in general. Looking for parallels with what he imagined I thought of him, we explored the difference between what he imagined his wife thought of him, and what she really thought of him. As he felt less criticized, anxious, and depressed, she scrutinized him less, and he began to feel more comfortable with her.

I also experienced my own discomfort with him. I feared that he would run out of things to say and that I would be exposed as not having anything to offer him. I was not able to work this through completely, but in retrospect I suspect that my fears of being found inadequate were both induced and my own.

He missed a fair number of sessions. Even accounting for the fact that business meetings came up last minute, it still seemed that he avoided his issues at times by not coming. I thought it might be fitting for this to be an imperfect therapeutic process, and that my accepting that was going to be instrumental in his progress.

Despite how imperfect it was, he did make progress. Candor, which had been ego dystonic, was becoming ego syntonic. His coping strategy was changing, and we both came to enjoy his increasing freedom to be himself in the sessions.

Treatment Process: The Agents of Change

My goal in treatment with most compulsives is to enlist their natural impulse to become a “better” person and put it in service of their psychological growth. With Bart I never used the word compulsive, much less mention the diagnosis “OCPD.” But I did note his strong, natural drive to succeed and to be a good person.

Bart did seem to get this eventually: “It’s kind of like I’m waking up and realizing that the game I was playing, putting points on the scoreboard, was meaningless, but this process of understanding myself and feeling better is more important. It feels good when I get it, when I master it.”

These realizations included questioning the narrative that he had to be like either of his parents. Near the end of his treatment he told me, “I want to take the best of my mother and father, and not be so black-and-white about it.”

Another aspect of his narrative that we needed to question was whether his family needed him only for money.

Maybe they wanted him to be happy as well. Accepting this as a possibility required some vulnerability on his part. He couldn’t remain aloof if they actually cared about him. I believe that his work on opening to feelings in our sessions was instrumental in allowing him to feel closer to his family.

On occasion he wanted assignments for the week. I chose exercises to help him become more aware, in the moment, of how his old coping strategy affected him. For instance: “Try to notice when you stop yourself from feeling good. Count the times you do it. Just noticing it is great.” And, “Notice how many times perfectionism leads you to attack yourself.” Compulsives love to count. What he counted was changing.

We explored different parts of his personality. “What if I’m an asshole that just likes money? What if I just like being seen as generous but I’m really not?”

“Yes, part of you likes money, and part of you likes being seen as generous. Those are both okay. And there is more to you. There is also a part that genuinely likes to be generous whether anyone sees it or not.”

He wondered if it was okay to be ambitious. Somehow it didn’t feel right. The more we processed this, the clearer it became that it wasn’t so much money that was important to him, but achievement and mastery. There was a part of him that loved challenges. To say what he loved was a new expression and marked acceptance of a part of him that he had only vaguely recognized before.

Accepting his introversion was another challenge. He definitely liked his time alone but felt guilty about it, which of course meant that spending time with his wife and others felt like it was in the “should do” column, not the desire column. In the long run, he came to appreciate both being alone (without guilt) and spending time with his family, because it was no longer a “should.” As different parts of him came out of hiding, it became clearer what was important to him.

All these elements served to reduce the insecurity he felt, so that he didn’t need to prove himself…as much.


After 19 months Bart felt well enough to end treatment. We spent a few weeks processing the termination, especially what it was like for him to end it rather than me. I would have liked to see him longer, but that may have come out of my own perfectionist ideas about how long treatment should go on and what it should accomplish.

I would like to have seen him develop more comfort with the therapeutic process itself, but that too comes from someone whose intense interest in psychology developed when he was a teenager. Maybe not everyone needs to be comfortable with therapy, much less actually enjoy it. It was a very good sign that he decided to end treatment rather than feel he needed to stay to please me. I hope my acceptance was healing.

I will never know how much, if any, of his progress was a well-performed recovery. But I suspect that even if his first efforts to be authentic were to please me, they eventually became truly authentic. I suspect that he had experiences and insights that will help him change and be more fulfilled, even well after our work is finished.

Working with compulsives has forced me to examine my own biases, my own need to control, and my own rigidity. If nothing else, I learned that I can’t expect my patients to become any more flexible than I am myself. This includes challenging my own fixed ideas of how treatment should go with each new client.

Conclusion: Poison as Medicine

Jung said that individuation is a compulsive process, that we are compelled to become our true, authentic selves. When that process is blocked, neurotic compulsion ensues.

When we recognize the constructive potential of the obsessive-compulsive personality, we can help make it less “disordered.”

When we recognize the energy that’s gotten off track, we can help direct that energy back toward its original, healthier path. The adamancy about doing the “right thing” that turned against the client and the people around them can be enlisted to help them find their way to a more satisfying way of living.

The alchemists were known for trying to transform lead into gold, which was really only a metaphor for transforming the poisonous, dark struggles of our lives into the incorruptible gold of character. But I think that this metaphor works best when we understand that the gold was there all along, obscured and waiting to be released.


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