In my over thirty years in clinical practice, I have run into many challenging problems and issues. These challenges included severe treatment-resistant depression, debilitating obsessive compulsive disorder, and extreme cases of borderline personality disorder among many others. In the vast majority of cases, most clients eventually manage to get much better. But the most vexing issue I have ever dealt with did not involve a diagnosis at all–in the usual sense. It has nothing directly to do with anxiety, depression, eating disorders, or behavioral problems. It is not listed as a symptom of any particular personality disorder.

However, before I tell you what it is, I’d like to ask therapists, counselors, and clients what problems they have found to be the most difficult to deal with in their lives. What issues put up the greatest fight when you’ve tried to confront them? What, if anything, has confounded you and left you feeling stuck over and over again? Did you finally manage to move ahead?  If so, how did you do it?

I’d love to know!

Obsessions are unwanted thoughts, images or impulses (such as that doorknob is contaminated or I think I might have left the stove on). Compulsions are the rituals or actions that a person performs in order to reduce the feelings of anxiety or distress caused by the obsession (like washing hands repeatedly, or checking to be sure the stove is off over and over again). People with OCD suffer. They often have trouble getting through day to day responsibilities, keeping healthy relationships, or enjoying life.

Our best friends, dogs, can also suffer from OCD. The cause of OCD in animals, like people, is thought to involve genetics, environments, and sometimes illness. A dog with OCD may be genetically predisposed to the disorder. The pet could be stressed by separation anxiety, or bored. Occasionally, an illness can cause an animal to show signs of OCD. Pets with OCD show repetitive behaviors that seem to have no purpose. These behaviors can lead to infections, poisonings, obstructions, and very annoyed owners. Most animals do these things from time to time (especially when young, bored or anxious). But dogs with OCD do these behaviors over and over and over again. Common OCD behaviors include:

• Tail chasing
• Licking
• Scratching
• Barking at nothing
• Running after lights or shadows
• Eating or chewing (after puppyhood)

It’s tax time. Our accountant called to ask for another piece of paper. The regular drawer in which I stow stuff to do with mortgages is stuffed with large folders from various mortgage and title companies that we have dealt with over the last decade. Couldn’t find the paper—took out everything and slowly sorted through each folder—thinking that maybe the paper got stuck in with another stack. Anxiety starts to build.

I start looking in another drawer, another filing system. This one contains recently paid bills, car insurance, health records, and stuff like that. Thought maybe that paper would be in with the mortgage payments—no paper. Although I am quite aware that I could call the title company and get another copy, this quest is getting too important. By now, my heart rate has increased and my mind is quickly filling with obsessional thoughts: “What if I die and my kids have to sort through this mess?” and “What’s wrong with me that I can’t remember where I put that paper?” Then, “Am I getting early dementia?” Finally, “If I make it though this, I vow to get better organized!”

Anxiety is normal and only considered a disorder when it significantly interferes with day-to-day living. A critical element of treating most anxiety disorders is exposure. Basically, exposure involves facing what you fear. Depending on your specific fear, this exposure can either be real or in the imagination. For example, someone with a deep fear of cats might start out by thinking about cats, talking about cats, and looking at pictures of cats. Then after those situations become routine, that person might go to a shelter and look at cats, then progress to touching cats.

Treating some fears, like fears of getting cancer, obviously can’t be combated by real exposure. You wouldn’t suggest that someone expose themselves to cancer-causing chemicals to beat a fear of getting cancer. A common way of getting around the issue would be to imagine or talk about “the worst case scenario.” That technique involves exposure in the imagination. So, someone with overwhelming fear about getting sick might be asked to describe the most feared outcome. Exposure might involve several sessions of describing, imagining, and thinking about that worst case.

When I meet new people, they often tell me about someone they know that has some sort of emotional problem. Many people give me a synopsis of symptoms and ask whether or not a person has obsessive compulsive disorder, anxiety, attention deficit disorder, depression, or borderline personality disorder. I’m pretty quick to say that I don’t ever make a diagnosis without seeing a person, but can talk about some qualities that might suggest this or that. I almost always point out that emotional problems are different than physical ailments; they tend to be more dimensional and less categorical. At this point, most people are stifling a yawn and moving on to the next topic (or in your case blog).

But our blog readers tend to be persistent, so let me continue. In the medical model, which psychology too often tries to emulate, a person has a disease and that disease can, in most cases, be verified by a medical test. For example, your biopsy reveals cancerous tissue or your blood test suggests that you have been invaded by parasites. Or the sore throat, fever, and a positive culture are consistent with a diagnosis of strep throat. Good medical diagnosis then hopefully leads to specific, specialized treatment.

The diagnosis of mental disorders is not so black and white. You don’t catch depression. And the symptoms of depression can look very different among people. Some with depression sleep too much or eat too much. Some toss and turn all night and lose their appetite. Some weep; others rage. There’s no blood test or MRI for assessing a diagnosis of depression. And unlike pregnancy, you can be just a little anxious or depressed.

The same diagnostic issue is even truer for what are known as the personality disorders. For example, the diagnosis of Obsessive Compulsive Personality Disorder (which is different than the more commonly known, Obsessive Compulsive Disorder) requires a person to demonstrate four of the following eight symptoms (according to the DSM IV TR):

• Preoccupation with details, rules, and lists
• Perfectionism that interferes with finishing projects
• Unable to throw away worthless objects
• Unable to delegate tasks
• Miserly spending
• Inflexible, scrupulous over conscientiousness
• Devotion to work to the …
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The way you interpret an event makes a difference in the way you end up feeling. People with OCD may make great progress with treatment yet sometimes they experience setbacks. The way you deal with that initial return of symptoms can determine whether your lapse turns into a relapse.

The following story about Jerry and Tim illustrates how two differing perspectives on a re-emergence of an obsession led to a big setback for Tim, but had relatively little impact on Jerry.

Jerry suffers from contamination OCD. He was first referred for help when his doc noticed that his hands were raw and bleeding. Jerry confesses that he often spends an hour in his shower and washes his hands hundreds of times most every day. After 10 sessions of exposure and response prevention (ERP), Jerry’s symptoms are under control. Yet, Jerry continues to have times he worries about getting contaminated. He recalls that his treatment included how to handle these occasional thoughts. He tells himself that the obsessions are normal and to be expected. He purposely waits until the thought passes and does not engage in compulsive washing. He knows that if the thoughts get worse, that he can always return to therapy for a few booster sessions. Most days Jerry feels that he is leaving OCD behind him despite his occasional lapses.

Tim also has contamination OCD. He too washes compulsively and avoids public places. His washing takes up hours of his day. Tim visits his primary care doctor to see if he can suggest something to help him. The doc talks to Tim about different kinds of treatment. Tim chooses to go on an antidepressant to see if that will help him. Tim’s doctor reminds him that the medication can take a long time to have an effect. Tim is relieved he may get better. After about 8 weeks, his symptoms seem to lesson. He doesn’t always think about contamination and has reduced his washing.

An early flu season hits and Tim comes down with the flu. He finds himself obsessing about what might have made him sick. The more he thinks …

The other day, our grandchildren came in from playing outside all afternoon–dirt and mud covering every inch of their feet, legs, trunks, hands, arms, faces, and even their hair. They were smiling and giggling with no concern for their hygiene or appearance. Obviously, a bath was in order for all.

This incident triggered a memory of one of the “Parts of Ten” chapters from our book Obsessive Compulsive Disorder For Dummies. We were inspired to write that chapter because those with OCD so often worry about becoming ill from the slightest contact with dirt. At the same time, few people know very much about dirt, whether they have OCD or not.

Here’s five items (from out book chapter) that you may not know about dirt:

• Dirt generally evokes negative connotations such as disgusting, filthy, unsanitary, corruption, or obscene. Yet soil, which is also dirt, has a positive meaning. Soil consists of hummus and bits of disintegrated rock and most crops need it to grow. So in spite of all of those negative connotations, we need dirt to survive.
• Dirt isn’t dead. Dirt is teeming with life. Sometimes as many as 100,000 worms live in a single square yard of dirt. But you can also find fungi, bacteria, algae, protozoa, and other forms of life in dirt.
• A little dirt is probably good for you. Kids who grow up in unusually sanitary, pristine environments actually have a higher risk of allergies, autoimmune diseases, and asthma than kids who have pets, large families, and attend daycare. Of course, we’re not recommending squalid conditions, but maybe knowing this information can help ease up on having a spotless home all of the time.
• Dirt isn’t what it used to be. Humans have systematically leached nutrients out of soil without replacing them. The effects on agriculture, especially in poor countries haven’t been good.
  Kids eat a little dirt with almost no ill effects. You know that kids stuff almost anything into their mouths. Toddlers manage to consume about 500 mg of dirt quite frequently. Assuming the dirt isn’t laced with pesticides, lead, gasoline, and such, they do so safely without harmful effects.
• On the other hand, a few kids …
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We love the wealth of information available to us from the internet. Because of our various interests, Chuck and I both have “Google Alerts” for articles or blogs about subjects we write about. (If you don’t know what Google Alerts are, Google it!) Many days, the shear number of suggested links and articles gets a bit overwhelming; both of us spend hours digging into the topics presented to us on these alerts. Frankly, lots of the topics are thinly veiled advertisements for various products and we quickly delete them. However, some alerts send us to fascinating research or poignant news articles.

One such article today detailed the suicide of a 21 year old woman in the UK who had battled Obsessive Compulsive Disorder and depression. The article chronicled a life that for this woman seemed unbearable. She apparently used 10 bottles of hand wash every day, and like many people with contamination fears had infected and blistered hands. She was afraid to get treatment because she feared that she might get contaminated from the facility. So, she dressed in her best clothes and jumped from the 10th story of a parking lot.

The saddest part of this story is that OCD left untreated often leads to depression. The vast majority of people with OCD or depression do not commit suicide, but the risk is certainly greater for them than others without these disorders. Sorry to bring this up during the season to be jolly, but people with OCD and depression don’t usually get better because of the brightness of the holidays. We have a few messages:

• There are effective treatments for both OCD and depression. These treatments should include some type of cognitive behavioral therapy. Medication can also be considered but is not always necessary. Many people don’t realize that empirically supported psychotherapies are at least as effective as medication for these problems and usually do a better job of preventing reoccurrences.
• There are many products, cures, and solutions offered on the internet. Some of these treatments are cleverly packaged with pseudo-scientific authenticity claims. Please be careful about buying something that offers a quick fix.
• If you or …
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You’re going to see lots of blogs on this topic in the next few weeks. However, we recommend getting a jump on these issues early.

Do you suffer from depression, anxiety, or obsessive compulsive disorder? If so, the holidays may cause you to crash. You could find that panic attacks that had been dormant, reemerge. Or compulsions to clean, count, or arrange things uptick to the point you barely have time to do anything else. Sadness may deepen and you’re not sure why. For that matter, even if you don’t have some type of depression or anxiety disorder, the holidays sometimes create considerable stress and anxiety. Why? Consider these possibilities:

• The stress of choosing gifts for people who are impossible to buy for
• The stress of deciding how much to spend in an seriously impaired economic climate
• The stress of seeing family that bring up painful issues from childhood (one of our favorite cartoons depicts a banner stretching across a huge ballroom declaring something like “Conference of Functional Families” with a single person standing alone in the room reading the sign)/li>

• The stress of attempting to prepare a fancy holiday feast, wanting everything to be “perfect”
• The stress of being around overly critical family members
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Losing a job, worrying about holding on to a job, or fearing ever being able to find a job-these concerns are greater than ever in this economy. Lots of baby boomers look at dwindling retirement accounts and worry about how they will have enough to live on. Young people struggle to find their first jobs and layoffs affect almost every extended family. The shrinking economy has lots of people stressed out. Stress and OCD don’t mix very well. We know that obsessions and compulsions become more frequent and increase in severity when people with OCD experience stress and worry.

Furthermore, even if you have never had OCD, it’s possible for symptoms to appear when you’re tense and worried. Obsessions and compulsions can be ways of the brain to handle extreme fears or stress. For example:

Jan, a single mother, was laid off from work 6 months ago. She collected unemployment and cut expenses to the bone. For the first time she found herself shopping in resale shops when her kids outgrew their shoes. The family ate lots of rice and beans. She always kept a clean house, but lately Jan has been having worries about keeping her kids safe from germs. She spends her days cleaning and re-cleaning the house. She tells the kids that they can’t afford to get sick because her health insurance was cancelled. She starts to make them take showers when they come home from school and put their school clothes in the washing machine so that she can decontaminate them. Her oldest daughter, frightened by her mother’s strange behavior, phones her grandmother. “Grandma,” she whispers into the phone, “something’s wrong with mommy.”

Bill, a 67 year old retired autoworker understandably worries about the future of his health care benefits, pension, and retirement savings. These realistic concerns send him to his computer to check the daily news, stock market conditions, and the balances of his portfolio. The checking, rather than helping ease his tension, only increases his anxiety. He finds himself spending more time at the computer and less time with friends and family. Spending all day at the computer …