Podcast/Blog

Real-Event OCD: What is it and How To Treat it

Most OCD subtypes cause the sufferer to fixate on future-focused fears and outcomes.  However, those with Real-event OCD – also known as ‘real-life’ OCD – is distinguished by obsessions and compulsions surrounding an event that has happened in the past.

In the case of real-event OCD, the sufferer finds themselves scrutinizing and ruminating over past events. Doubting the things they’ve said and done, leaving them with immense feelings of guilt and shame that they attempt to navigate through compulsive behaviors.

Someone with real-event OCD will exert a great deal of energy to try and find certainty around a past event which makes it very difficult to live and embrace the present moment.

Real-event OCD can feel as though it steals from the present moment as the sufferer remains in a rumination loop, trying to analyze and scrutinize past events that often leave them feeling like they are a bad person.

Here we will explore the ins and outs of real-event OCD.

But first, a quick recap of the OCD basics…

An Overview of OCD

There are two core components that characterize OCD and all of the OCD subtypes.

These are obsessions and compulsions.

OCD is a common mental health condition whereby the sufferer experiences obsessions in the form of thoughts, images, urges, feelings, or sensations, which trigger extreme levels of uncertainty and anxiety.

As OCD is egodystonic – meaning it goes against our values and morals – those obsessions are disturbing in nature and leave the sufferer questioning their sense of self.

This is why intrusive thoughts are often described as ‘sticky’.

Because the very nature of these thoughts has us challenging who we are, they are perceived as a cause for concern and we believe they require our attention.

In a bid to manage the uncertainty and anxiety following these obsessions, the sufferer engages in compulsive behaviors that offer temporary relief.

These behaviors can present as physical or mental compulsions.

Common mental compulsions can include:

  • Rumination
  • Counting
  • Prayer
  • Self reassurance-seeking
  • Mental Review

Click here to join our newsletter and receive instant access to our 6-part mental compulsions series, teaching you how to resist the urge to do mental compulsions (with PDF worksheets)

Common physical compulsions can include:

These compulsions offer short-term relief but contribute to long-term struggle as they leave the sufferer trapped in the OCD cycle.

The good news is that this OCD cycle can be broken!

Effective treatment is available so you can begin managing the anxiety and uncertainty without needing to engage in compulsive behaviors.

The ins and outs of Real-Event OCD

We can all find ourselves reflecting on past events from time to time, wondering whether we should have done things a little differently.

We might berate ourselves for a moment about the things we have said or done that could have been handled more effectively.

We may even experience momentary guilt over the potential consequences of our past behaviors.

But for those without OCD, these reflections and feelings tend to fade over time. For those with real-event OCD, they find themselves over-analyzing, fixating, and ruminating on past events in a desperate plea to gain a sense of certainty.

They may be searching for definitive answers to suggest that they didn’t do anything wrong and that they aren’t a bad person.

A common compulsion within real-event OCD is mental review.

The sufferer will replay the moment over and over again.

Guilt and shame are overwhelming feelings that occur for those with real-event OCD. And these feelings brought about by such reflections are intense and painful to manage as they leave the sufferer questioning their morality and identity.

OCD takes hold of the past event and warps the sufferer’s perception, positioning them as the ‘bad guy’ or ‘villain’ of the piece, for which they can often call on self-punishment as the compulsion believing they deserve to be punished.

Examples of Real-Event OCD

Someone with real-event OCD can experience obsessions about a wide variety of past events. Anything from cheating in an exam, an argument with a partner, a job interview, or even an interaction with a stranger at the local shop. 

The common thread is that obsessions are almost always driven by the fear of being a bad person.

Common Real-Event Obsessions

  • Did I inadvertently cause that person to feel X,Y, or Z
  • What would have happened if I hadn’t said or done X,Y, or Z
  • Was that wrong? Did I commit a crime? Am I morally corrupt?
  • Am I bad person for doing/saying X,Y, or Z?
  • It’s because I did (X) that this bad outcome occurred
  • I’m the reason that person I care for is suffering, because I did/said (X) when I shouldn’t have
  • This negative circumstance is a direct result of this thing I did/said years ago

An example of how real-event obsessions may occur could look like this…

“A friend of mine told me she kept having heart palpitations and feeling faint but I simply joked and told her she was probably just unfit. She has now been diagnosed with heart disease which they would have caught sooner if I had taken it more seriously and told her to get herself checked. If she get’s seriously ill, this will all be my fault.”

Common Real-Event Compulsions

  • Mental Review – repetitively playing the event over and over again in their mind to find proof that what they believe about themselves or the event is true.
  • Self-punishment – criticizing and berating themselves because they believe they deserve to be punished for their past behaviors.
  • Reassurance-seeking – Excessive reassurance-seeking from friends or family to clarify that they behaved ‘correctly’ or to confirm that they did or didn’t do anything wrong or inappropriate.
  • Apologizing – Someone with real-event OCD may excessively apologize to the person they believe to have wronged in the hope of gaining forgiveness.

We can use the obsession above to show an example of how the compulsion may then present.

This sufferer may replay the experience repeatedly in their mind noting what they believe they should have said or done differently. They may punish themselves by thinking, “You should have told her to see a doctor. You shouldn’t have joked about it. This is all your fault”

They may ask others whether or not they think this could have been prevented if they had told their friend to see a specialist sooner.

They may go out of their way to make up for their ‘wrong behavior’ by apologizing excessively to their friend. They may also go out of their way to do good deeds in service of the community to be forgiven for their ‘perceived error’ or ‘mistake’.

How to know if you’re experiencing Real-Event OCD?

It’s common for everyone to find themselves dwelling on past events from time to time. But here is a breakdown of symptoms to consider if you think you may have real event OCD:

  • Repeatedly replaying events in your mind
  • Over-analyzing the outcomes of your actions
  • Feeling excessive guilt, shame, or doubt about your actions
  • Apologizing excessively to those involved
  • Excessive reassurance-seeking to validate your experience
  • An intense and overwhelming feeling that you are a bad person

Someone with real event OCD can lose hours of their day ruminating and fixating on these past events. 

It’s almost always impossible to gain 100% certainty, but even more so when it comes to analyzing past events that have come and gone. Because of this, those obsessions always tend to crop back up.

You can find yourself trapped in the past and unable to engage and enjoy the present moment and struggle to shake this overwhelming sense that you’re not a good person.

However, if you are able to change your relationship to those obsessions and resist the urge to do compulsions, you can find long-term relief from real-event OCD.

Treatment for Real-Event OCD

As with all OCD subtypes, the best course of treatment for real-event OCD is ERP therapy (exposure and response prevention).

ERP is deemed the gold standard treatment for OCD and has been shown to be highly effective. This means that it is highly possible for you to fully recover from OCD using this treatment.

In ERP, you work with your therapist to place yourself in scenarios that gradually and intentionally trigger your obsessions. You will work together to navigate the uncertainty and anxiety and resist the urge to do compulsions.

Your brain learns that you are capable of managing anxiety and uncertainty without the use of compulsions. Each time you engage in compulsive behaviors you strengthen OCD’s hold. When you resist the urge to engage in compulsions, you can learn new ways to respond to your obsessions that will – over time – reduce the anxiety.

ERP for Real-Event OCD

Most highly trained ERP therapists will first provide thorough psychoeducation on real-event OCD and train you to engage in effective response prevention.

Response prevention is a component of ERP where we practice reducing any compulsions that the person with real-even OCD is engaging in.

Research has shown that ACT (acceptance and commitment therapy) is a highly effective modality supplement to ERP, where the person with real-event OCD practices working with value-based behaviors rather than fear-based behaviors and learns how to manage their intrusive thoughts using tools like diffusion and mindfulness skills.

In the case of real-event OCD, a common form of ERP therapy is to use an imaginal exposure script.

An imaginal script for real-event could be writing out the story as it happened, as specifically as possible, so that you can use their mindfulness, ACT, and ERP tools to resist the urge to do compulsions.

In addition, other exposures that may be helpful and beneficial are engaging back in any behaviors that you have been avoiding. You and your therapist will work together to make sure the exposures you do are exposures that you feel will be helpful and worth engaging in.

Finding a qualified therapist

Real-event OCD can sometimes be tricky to diagnose and treat. The nature of most OCD types means they are driven by the fear of what might happen in the future whereas real-event OCD is driven by the fear of what’s happened in the past.

We highly recommend you want to do your due diligence and be sure to work with an OCD specialist who is ERP trained as this is the most effective treatment for OCD and yields incredible results. It is important to work with a qualified mental health professional who can offer an accurate diagnosis and support you with the best treatment plan.

If you are based in California, our friendly team of elite OCD specialists can help you navigate your OCD and support you on your recovery journey.

Please reach out to us by submitting an initial intake form here to see how we can best support you.

If you do not live in California, you can use the IOCDF directory to find support from a qualified clinician in your area.

ERP SCHOOL – Online Program

For an affordable and accessible alternative to private therapy, top OCD specialist Kimberley Quinlan, LMFT, has created ERP SCHOOL.

Learn to identify your specific real-event obsessions and compulsions and use science-backed ERP practices to manage your OCD symptoms.

This online program will help you change your relationship with those haunting thoughts and resist the urge to engage in compulsions.

You can no longer feel limited by fears of the past and live life fully in the present!

Join ERP SCHOOL here.

Just Right OCD: Causes, Symptoms, and Treatment 

We all understand what it feels like to have that instinctual feeling that something just isn’t right, it just feels a little bit ‘off’.

We can’t always explain why, but we have that overwhelming desire to go and ‘fix it’ in some way. We do this until we feel as though things are as they should be.

Everyone experiences this, but for someone with Just Right OCD that feeling is relentless and hard to shake.

Unlike most other OCD subtypes, Just Right OCD is driven by a sense of incompleteness or incorrectness.

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Ep. 322 5 Relationship rules that have changed my life

Five Relationship Rules That Have Changed My Life | Ep. 322

Today, we’re talking about the Top 5 Relationship Rules I have that have changed my life. This episode was inspired by a letter I wrote to all of you. For those of you who signed up for my newsletter, I give you tools and tips, and stories, and I tell you funny jokes sometimes. But I was writing the newsletter while I was in Australia just before I left when I was there in December, and I was reflecting on how beautiful my relationships are with my family now. And I was reflecting on why. Why are they so beautiful? Well, number one, they’re beautiful people. But number two, more importantly, I have learned these relationship rules, which have allowed me to have the most beautiful relationship with my family and the most beautiful relationship with my husband, my kids, my friends, and you guys.

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321 What do I do after (and during) exposures

What To Do During And After An Exposure? | Ep. 321

One of the most common questions I get asked is what do I do during or after an exposure? 

Number One, it’s so scary to do an exposure, and number two, there’s so many things that people have brought up as things to do, even me, this being Your Anxiety Toolkit. Maybe you get overwhelmed with the opportunity and options for tools that it gets too complicated. So, I want to make this super easy for you, and I want to go through step by step, like what you’re supposed to do during or after an exposure.

(more…)

OCD and Insomnia: How to sleep better when you have OCD

Studies have shown that those with obsessive-compulsive disorder (OCD) struggle with increased rates of insomnia compared to those without OCD.

We all have sleepless nights from time to time.

The stressors of daily life can have our minds racing and us tossing and turning through the early hours of the morning. This is very common. 

However, for those with OCD, obsessive thoughts can keep them stuck in a miserable cycle of not being able to switch off their minds. Trapped in a restless cycle of racing thoughts and sleepless nights, insomnia adds a new layer of difficulty when managing OCD.

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OCD & ADHD: Similarities and Differences Explained

Obsessive-compulsive disorder (OCD) and attention deficit hyperactivity disorder (ADHD) are two common psychiatric disorders.

A person with little knowledge of these disorders could confuse the symptoms associated with attention and concentration, believing one disorder to be the other.

However, the two conditions are wildly different.

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Is Skin Picking Disorder Related to OCD? (Excoriation Explained)

Unlike OCD which is classed as an anxiety disorder, skin-picking disorder (excoriation or dermatillomania) is known as a body-focused repetitive behavior.

Skin-picking disorder may also be known as a body-focused repetitive behavior. It may also be called an impulse control disorder due to an excessive and ongoing urge to perform the skin-picking act. And in other occasions may be named an ‘obsessive-compulsive spectrum disorder’ due to the features that overlap with OCD.

While skin-picking disorder and OCD are two separate conditions, people with skin-picking disorder are more likely to have OCD or OC spectrum disorders such as hair pulling, BDD, and tic disorders.

This is because of the urge to engage in those repetitive ritualistic behaviors that offer relief either from intrusive and unwanted thoughts, or negative feelings or emotions.

Let’s get into the differences between these two disorders…

What is OCD? A Recap!

Source: The London Psychiatry Centre

OCD is a mental illness characterized by obsessive and unwanted thoughts or urges followed by repetitive physical or mental compulsions done to reduce the resulting anxiety. 

It’s important to differentiate between everyday, low-frequency anxiety that many people will experience and disordered anxiety, brought on by these intrusive thoughts.

An intrusive thought may look something like this:

“If I don’t do X, then catastrophe Y will happen”

“What if this catastrophe occurs?”

When these thoughts arise, someone with OCD feels compelled to solve for the uncertainty and anxiety that arises. This is why OCD is sometimes known as the ‘doubting disorder’.

OCD is egodystonic in nature which means the obsessions experienced by the sufferer goes against their values.

Unsurprisingly, when a disturbing thought arises, the uncertainty surrounding it can feel unbearable.

The OCD sufferer may find themselves ruminating on what this thought must mean about them and try to ‘figure it out’.

Why did I have this thought?

What does it mean about me?

What might happen if I don’t do something about it?

In an attempt to alleviate the uncertainty and anxiety brought about by this unwanted thought, the sufferer performs compulsions that offer short-term relief.

For example, someone with postpartum OCD may fear that their newborn child will stop breathing in their sleep. The compulsion might be to check on their baby at regular intervals which in turn disrupts their own sleep and has a greater knock-on effect to their mental and physical health.

Another example may be someone with contamination OCD. They may fear intrusive thoughts such as, “What if I catch a disease?” or “What if I get sick and die?”.

The compulsion in this example might be to excessively wash their hands and wipe down objects before touching them.

The disordered anxiety suffered by those with OCD can consume all aspects of their life. 

Social gatherings may be avoided, relationships become strained, and work or school can become difficult to focus on. OCD can be very scary, especially if obsessions are violent in nature, but it is treatable and manageable with the right help.

Click here to sign up for our weekly newsletter and receive immediate access to the 6-part mental compulsions audio series to help you resist the urge to engage in mental rituals (PDF worksheets included)

What is Excoriation Disorder?

Source: The Cleveland Clinic

Skin picking disorder or excoriation is characterized by the habitual picking of skin, commonly around your nails, pimples, or blemishes. 

People with dermatillomania may also create open sores by compulsively touching or picking at the skin, even if there is nothing there to pick at.

We’re all guilty of occasionally picking at our skin, but it becomes a disordered condition when it is near-constant and causes bleeding, open sores, or scars.

Although, to the untrained eye, skin picking may not seem overly distressing or a source for concern, those with excoriation disorder often find themselves trapped in a difficult cycle to break.

People may pick at their skin for a variety of reasons including boredom, anxiety, increased stress, or to cope with negative emotions.

While skin picking offers an initial burst of relief, it often follows with intense feelings of guilt or shame. Someone with excoriation disorder could spend hours each day picking their skin, thinking about picking their skin or trying to resist the urge to pick their skin.

It could be very easy for an observer to label this as an insignificant ‘bad habit’ but for the sufferer, skin picking can lead to greater implications that impact their quality of life.

It is not uncommon for those with excoriation disorder to avoid social events, isolate themselves from loved ones, have difficulty managing their condition at work, and fall into episodes of depression due to feeling ‘out of control’.

Are skin picking and OCD the same?

There are similarities between the symptoms of skin picking and OCD but they are not the same. 

They are, however, both categorized as obsessive-compulsive and related disorders under the DSM-V (Diagnostic Statistical Manual) due to their overlapping features and the frequency with which they are simultaneously diagnosed within individuals. 

It is the compulsive need to pick that lands this particular disorder in with other obsessive-compulsive and related disorders.

Medical reviewers have even found that those who suffer from skin-picking disorder are more likely to also have OCD compared to those without.

You can be a skin picker without OCD

For those with skin-picking disorder, the act of excessively picking skin is often done to alleviate the constant urge to pick or touch the skin. 

Similar tools are used with sufferers of OCD in that compulsive and ritualistic behavior is used to diffuse the uncertainty and anxiety felt by obsessive thoughts. 

However, a skin-picking disorder focuses purely on picking scabs, spots, and scars, and can occur without comorbid OCD.  You can receive an excoriation diagnosis without also receiving an OCD diagnosis. 

With OCD, there is a wider range of compulsive ritualistic behaviors as a result of intrusive and obsessive thoughts. For example, some compulsive rituals might include:

The urge to pick may be an obsessive-compulsive behavior but it is not, in isolation, a symptom of OCD.

When does skin picking become a problem?

Skin picking becomes a problem when it begins to affect your daily life. 

If skin-picking behavior gets to the point that it is near-constant, affecting your ability to see friends or carry out your responsibilities at work and school, this may be the time to seek a medical assessment to see if you are dealing with excoriation disorder. 

Someone with a skin-picking disorder can develop damage to areas of their body that are easily seen by those around them. Scars and skin damage to the face are incredibly common and can leave the sufferer feeling embarrassed and ashamed.

This is not a disorder to be taken lightly despite how minor it may appear to someone with little knowledge of the condition.

While people with dermatillomania may not want to stop picking their skin, they don’t like the consequences of doing so and they feel very controlled by these urges. They feel as though they have little control over this strong urge and they feel like they have to pick.

There’s a reason that disorders such as this are often accompanied by high levels of anxiety, stress, and depression. It’s because it can be psychologically and emotionally difficult to manage day-to-day life. 

It’s important to know that skin picking can be treated and managed so if you suspect you might be struggling with this condition, seek appropriate support from a mental health professional.

Both OCD and excoriation disorder – together or separately – can be treated effectively.

The ABC’s of Skin Picking

OCDLA created a simple and clear classification of dermatillomania to help us understand when skin picking becomes a problem. Because let’s face it, we all pick! But when does it start to matter?

“A” is something almost anyone would pick.

Something that anyone would feel inclined to pick might be some dry skin hanging from your arm or elbow, a scab that’s mostly fallen off, or a full spot on your chin that’s ready to burst!

“B” is a bump, pimple, or scab.

This is something that only a skin picker would pick at. At this stage, there is very little there to actually pick unlike the things noted in the “A” category. But a skin picker may feel for little bumps or potential spots and begin to pick.

Everything in the “B” category has the potential to turn into something from the “A” category or would disappear if left alone. But a skin picker will pick at these things and make them worse which ultimately causes high levels of distress and skin damage.

Those with skin-picking disorder may contribute at least 50% of their skin-picking to this category.

“C” stands for create.

Only someone with dermatillomania will find themself in band C. In this category, the sufferer does not pick at anything real per se, they pick at seemingly healthy skin and therefore create something such as a cut or blemish that was not there before.

In this category, the picker does not pick at anything apparent on their skin. Instead, they create skin damage through the act of picking at healthy skin.

What are the causes of skin picking?

Photo Credit: Engen Akyurt

The exact causes of excoriation disorder, like causes of OCD, are unknown. But there are a few factors that can trigger people to pick at their skin.

  • Boredom
  • Stress
  • Anxiety
  • Feelings of guilt or shame 
  • Acne or eczema (skin lesions)
  • There may be a spot or scab that is deemed unsightly that the person wants to remove

Research suggests that the disorder may be linked to genetics. A study from 2012 found that out of 60 people with excoriation disorder, 28.3% had close family members who shared the same disorder.

(OCD) and body dysmorphic disorder (BDD), two types of obsessive-compulsive and related disorders, are also more common in people with skin picking disorder than in those without the disorder. 

Research figures highlight that 28% of those with BDD also have excoriation or skin-picking disorder.

Two types of skin picking:

Automatic: This type of skin picking is more habitual and can be done without a person knowing they’re even doing it. Within this type of skin picking, the person may be seen running their fingers over their skin to check for any areas that feel different and could be a focus area for skin picking. This behavior is also known as ‘scanning’ and can be described as being in a trance-like state. In this trance-like state, they can lose track of time completely and fall into trance-like behaviors when they are picking.

Focused: This type of skin picking is more intentional, and an episode can last four extended periods of time, leading to greater skin damage.

What are the symptoms?

Source: CalmSage

There are several symptoms of skin-picking disorder:

  • Excessive and compulsive picking
  • Picking to the point of skin damage – being required
  • Digging into the skin using fingers, tweezers, knives, teeth, etc.

Common areas of focus such as the face where acne may be present are typical, and moles or freckles are targeted in an attempt to remove what is considered a blemish. 

People with skin picking disorder will exhibit behaviors absent-mindedly, scanning for areas without much thought, but they can also have focused “sessions” where specific areas are targeted with picking lasting for hours at a time. 

This is the more severe behavior trait and in some cases can result in surgery.

Diagnosis of skin-picking disorder

Source: Diana Polekhina

Diagnosing excoriation disorder requires a physical exam from a healthcare professional and some questions about any skin-picking behaviors to try and figure out if a skin-picking habit has crossed into a disorder. 

Diagnosing this condition requires meeting all five of the following criteria:

  1. Recurrent skin picking that damages the skin.
  2. Repeated attempts to stop or to do it less often.
  3. Detrimental impact on various aspects of your life because of shame or embarrassment due to skin picking.
  4. Skin-picking behavior occurs without the influence of any other medical condition such as scabies, eczema, acne, or drug use, whether recreational or prescription.
  5. Picking isn’t the result of another mental health condition, such as body dysmorphic disorder, where you believe that you have a perceived physical defect that impacts your sense of self-worth and self-confidence so you pick at your skin to relieve those negative feelings.

Treatment for OCD

Source: Brooke Cagle

OCD is a long-term condition and the treatment for OCD will reflect this. The most effective treatments are psychotherapy and medication.

  • Psychotherapy

Cognitive behavioral therapy or CBT is used for many psychological problems, including OCD. Exposure and response prevention (ERP), is a type of CBT that involves gradual exposure to obsessions while resisting the urge to perform compulsive behaviors as a coping tool. The aim is to help teach your brain that you are capable of managing anxiety and uncertainty without the use of these coping mechanisms.

  • Medication

Antidepressants known as selective serotonin reuptake inhibitors (SSRIs) are designed to increase the levels of serotonin in the brain. These are often prescribed alongside psychotherapy.

Medication should only be taken if prescribed by a mental health professional. Please seek medical assistance and effective medication treatment that is tailored to you and your needs.

Treatment for excoriation disorder

Source: Andre Hunter

Medication isn’t used to treat excoriation disorder, treating skin-picking disorder follows two main kinds of psychotherapy…

As with OCD, CBT has been shown to be effective at treating excoriation disorder by helping to change how their relationship and response to stressful or overly emotional situations. More specifically, a technique called habit reversal training is used to help identify what causes these urges and develop alternative, less harmful behaviors. 

Making changes to your surroundings and limiting the opportunity to act on urges to pick is also effective.  

This is known as stimulus control and a therapist will work with you to make it harder to act on these urges. Wearing gloves or band-aids can help by reducing the opportunities to pick and other changes, such as removing mirrors or covering reflective surfaces, limits exposure to face acne or other blemishes that may usually trigger the urge to pick.

319 Let's do an Anxiety Audit (with Lynn Lyons)

Let’s do an Anxiety Audit (with Lynn Lyons) | Ep. 319

In this week’s podcast, I talked with Lynn Lyons about her new book, The Anxiety Audit (7 Sneaky Ways Anxiety Takes Hold and How to Escape Them).

We discuss: 

  • How repetitive negative thinking disguises itself as problem-solving 
  • How catastrophic thinking makes the world a dangerous place and demands you react accordingly 
  • How big conclusions and an all-or-nothing approach make the world smaller and harder to navigate. 
  • How a fear of judgment isolates and disconnects us from people 
  • How being busy and overscheduled both adds and masquerade anxiety and stress 
  • How we blame others when we are irritable
  • How self-care becomes not self-care at all
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318 The ONE Thing I Want You to Focus On in 2023

The ONE thing I want you to focus on in 2023| Ep. 318

This is Your Anxiety Toolkit – Episode 318, and welcome 2023. 

Welcome back, guys. Happy 2023. Happy New Year. I want you to imagine you and I are sitting down at a table and we both have the most wonderful, warm tea or coffee or water or whatever it is that you enjoy, and we are going to have a talk. You’re not getting a talking too, I’m not saying that. But I want you to imagine that I’m standing in front of you or sitting in front of you and we’ve got eyes locked, and I am dead serious in what I’m talking to you about because I believe it to be the most important thing you need for 2023. I really, really do. 

So, let’s talk. Okay, you’ve got your tea. I’ve got my tea. Let’s do this. Okay.

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