Wrestling with OCD

If you have suffered with Obsessive Compulsive Disorder (OCD), or know someone who has, you are probably familiar with those distressing, intrusive thoughts that create so much anxiety. Traditional psychoanalysis used to focus on the content of those thoughts and seek to uncover the deep, buried wounds and wishes that led to these strange, seemingly alien notions. Thus the woman who was obsessed with the fear that her child would get hurt walking to school might be analyzed and advised that she seems to have a deep resentment against the child and all the responsibilities of motherhood and the worry is really an expression of an unconscious wish to be rid of the child. Talk about a guilt trip…!

Modern research and practice in treating OCD tends more towards the notion that everyone’s brain generates random and sometimes pretty crazy-sounding thoughts. Thus, the treatment is much less about wrestling with the particular content of the OCD thoughts and more about learning to compassionately notice that thought happening among all the other thoughts firing off like popcorn in the typical brain, use strategies to calm down the anxious physical reaction to the thought and refocus, gently and purposefully, on what one would rather think about at that moment in time. It stops becoming “Don’t think about X,” (try that: right now, I forbid you to think about pizza. Ha – how long did it take to imagine a pizza?). Instead, it becomes, “Yup, there’s that thought about X…and now I will take a deep breath and refocus on what I was doing/what’s going on right here and now.”

This is what mindfulness, stress management and cognitive-behavioral therapy can do, together, to help with OCD. The brain changes in response to choosing these behaviors, and the degree of physical distress decreases throughout the whole body.

If you are suffering with OCD, this kind of very well-researched approach may be what you need. Please contact a professional in your area if you think this might be helpful for you.

Dr. Lori Puterbaugh, LMHC, LMFT, NCC

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.


What can it be, besides ADHD?

Your child is bouncy. He doesn’t seem to pay attention; she forgets to follow through on tasks. The book bag is a disaster area; necessary books never seem to make it home; and you regularly have to turn around and go home to pick up shin guards or ballet shoes.

Well, what can it be, besides ADHD – the psychiatric diagnosis of Attention Deficit/Hyperactivity Disorder, diagnosed off a checklist and sometimes suspected of being over-diagnosed?

The symptoms associated with ADHD can be due to a wide variety of issues; here are a few:

  1. Stress at home or in the environment. If you are having marital or other family difficulties, your child is stressed – whether you know it or not. Research indicates that a, adults are pretty lousy of telling when children are anxious or worried and b, the children of adults with marital problems, when tested in research studies, have high levels of stress chemistry metabolites in their urine.
  2. Maybe it’s not at home; maybe it’s the environment. Live in a noisy and/or high crime neighborhood? Is your child bullied or afraid of being bullied at school? Sources of ongoing stress will interfere with the parts of the brain that are important to focus, attention and memory.
  3. Insufficient sleep. Is your school-age child getting 9 or 10 hours of quality rest per night? Falling sleep by television, computer, or with a cell phone close at hand? These will all interfere with quality and quantity of sleep.
  4. What are overtired kids like? You know what you do when you’re driving late at night and you are too tired to be driving – so you bounce in the seat, sing too loudly and pretend having the windows open will magically keep you alert? Yeah, well…meet the 3rd grade kid who is up too late because of football or soccer practice a few times a week and fidgets around looking dazed in class.
  5. Insufficient exercise. The recommendation for children is two hours of physical activity a day – real activity, not standing-around-hoping-coach-lets-me-play-this time activity.
  6. Boredom. Brains + boredom = either shutting down and not trying at all OR driving grownups and other kids bonkers. Look out for the introverted or shy child who may shut down and go into dreamland; a lot of gifted children are very introverted and self-contained, and unlikely to be overtly disruptive. They simply tune out.
  7. Frustration. A child who is having difficulty – perhaps an undiagnosed or insufficiently supported learning disability – will often give up and stop trying. Remember that children personalize things; if they are struggling and the grownups act like they “should” be able to “get it,” the child assumes the adults know best and that the child must be flawed/”stupid” etc.
  8. Your (or some other involved grownup’s) inconsistency. If you flipflop on rules, fail to follow through, and run an unpredictable life for yourself and your child, it’s not fair to look at the child who seems scattered or (more likely) is gambling on this being one of those times when you are too stressed or preoccupied and let things slide, and blame the child.

You’ll notice that none of these issues can be blamed on the child. These are all grownups-need-to-pay-attention flags, not “naughty kid” flags. So, before you assume your child has a brain disorder, rule out the many factors that we grownups often unwittingly inflict on children and see if, with a few months of more consistent attention to these risk factors, your child’s behavior and morale improve.

Dr. Lori Puterbaugh

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.


Avoidant Personality Disorder, Social Anxiety, or Just Shy?

Simple shyness? Social Anxiety Disorder? Avoidant Personality Disorder? What’s the difference? Are we just pathologizing normal behavior? Why so many labels?

Well, the labels exist to help professionals differentiate between constructs. That’s what most diagnoses are: categories put together by committee, identifying particular experiences or patterns of behavior, thinking and/or feeling that tend to co-occur. That’s an extreme simplification, but it’s a good jumping-off point for us.

Shyness is normal-people-speak. It’s the way we describe someone, or ourselves, when we are a little reluctant to “blow our own horn” or “put ourselves out there” (whatever THAT means). A little shyness means some mild worry about doing the right thing, not embarrassing ourselves, and wanting to avoid being a nuisance.

Social Anxiety Disorder (SAD) is a psychiatric label that covers a level of shyness that interferes with someone’s daily life. That’s the test: whether the person’s regular life is constricted by worry about saying/doing the wrong thing in social settings and a tendency to avoid social gatherings or work or school related activities. It’s anxiety: there are both physical symptoms of fight-or-flight (elevated heart rate, for example, or more perspiration) and psychological symptoms (worrisome ideas about being in the spotlight and doing something “stupid,” for example). People with SAD usually have close relationships and get through daily life pretty well, with bumps along the way when big events or unusual circumstances – public speaking at a work meeting, for example, or large gathering – looms.

Avoidant Personality Disorder (APD) is sometimes confused with SAD. ADP is markedly different, though, because it encompasses a global low self-esteem and fear of being judged and found wanting in just about every way. So, for example, the person with some social anxiety has close friendships but might feel a bit anxious about going to a wedding reception with a lot of people s/he doesn’t know. The avoidant person has few close relationships out of fear of people finding them just not good enough to be friends. The APD person suffers anguish before annual performance reviews, and even gentle constructive criticism is received as devastating evidence of how deficient they are.

The fear is not “just in their head.” Fear is always a full-body experience. When a situation seems to be a threat (for the person who suffers with APD) to be judged and found wanting, the body responds before the logical, higher brain has even identified what is happening. So the amygdala has sounded the general alarm – the endocrine system flies into action, and as a result logical assessment is curtailed. Telling someone whose heart is pounding, whose blood is full of adrenaline and a massive dose of glycogen and is primed to run away that they are just overreacting is not helpful. Learning how to manage this, how to recover from the old messages of being “less than” and “not good enough,” is a process, not an instant fix. It can be healed.

There’s much more to these labels and to the details of treatment, of course, but perhaps the useful take-away today is: help is available. A lot of people will find that solid self-help approaches based in cognitive-behavioral therapy research (David Burns, MD’s books are excellent examples of these) quite sufficient for mild to moderate social anxiety. When that anxiety is all-pervasive, and there are few relationships out of fear of being found wanting, and loneliness and fear of being judged rule one’s life, the additional support of a counselor might be more helpful than trying to struggle through alone. Ironically, group psychotherapy can be quite effective for these difficulties – but it’s hard to find them.

If you know someone who is struggling, try to help them get help.


Dr. Lori Puterbaugh

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

Why are personality disorders so difficult to treat?

Why are personality disorders so difficult to treat?

Well, there’s a complicated question! This post attempts to present an overview response.

A personality disorder, like just about all mental disorder diagnoses, is made based on a checklist of complaints, symptoms, and observations. However, personality disorders are very different from what we normally think of as emotional problems.

Consider, for example, depression. “Depression” is diagnosed when 2 weeks have passed and certain criteria have been met (and there’s no “pass” given for grief or other traumatic events in the new diagnostic manual, although we’re supposed to note it in the records). Most people know when they’re sad, irritable, unhappy, and hopeless. It feels awful and they want to get that bad feeling off of them. Some people might not think of it as “depression.” They might identify it as a “low time,” or it might be grief, or a normal adjustment to a new phase of life such as marriage, an empty nest, or graduating from college. It might be a normal but very painful response to some new curveball life has thrown at them: an illness, a layoff, retirement, etc.

A personality disorder is different because it is pervasive; like the personality of any person, it is part of everything. Your personality impacts how you interpret everything that happens, the way you react to people and events, the emotions you experience. This goes for healthy people as well as those whose patterns are far enough from the big, wide range of normal to merit a “disorder” status. So, when someone seems to have a personality disorder (say, narcissism), they are not experiencing their diagnosis as a messy, icky experience to be stopped. They are rolling along (over other people) and having their life. Everything comes through a lens that assures them that they are special, entitled to preferential treatment and to have their way, and, well, let’s face it, just better than us. Problems are experienced as due to the outside world and their own role in those problems is not apparent.

From a therapist’s perspective, when someone comes in with depression, even if that’s not what they, or we, might call it, they know they are unhappy and they want very much to feel like themselves again. They are hopeful that a counselor can help them push through this difficult time.

When someone who meets criteria for a personality disorder comes to treatment, it’s usually because of some other issue, such as work or relationship problems. Remember that each of us is walking around, seeing the world through our own eyes and interpreting everything we experience, including our own thoughts and feelings, through our unique mental structure. You build that mental structure from the earliest moments of life. Is the world safe? Are my needs met? Are the grownups who tend to me patient, gentle and kind? Babies are already sorting out information and creating a set of basic assumptions about the world that will become essential aspects of their personality. It’s so deep, it’s hard to not take for granted that our way of making sense of things isn’t necessarily the only, or best, way. So when patterns of problems arise with colleagues, bosses or family, it’s hard to believe that the problem is fundamental to our mental structure; it defies logic and could be very insulting. The person may be suffering terribly, every day. This is definitely the case with some of the personality disorders, such as Borderline Personality Disorder, Avoidant Personality Disorder and Dependent Personality Disorder. Whether these or any of the personality disorder diagnoses, the person did not choose this burden and it isn’t their fault. However, presenting it as an internal problem – to them – can feel like blaming and attacking – which is definitely not the therapist’s intention.

Imagine if something terrible happened to you: a tsunami. Your workplace is destroyed. You lose your house. You lose your stuff. You catch a mosquito-borne illness and suffer long-term ramifications. It’s a series of terrible events and you find yourself traumatized and perpetually anxious. Is that anxiety your fault? Certainly not. Just so, the early life experiences that set people up for the challenges we call personality disorders are not their fault. However, it’s a problem that they can learn to heal, but that can sound like blaming the victim. Thus, if someone meets criteria for a personality disorder, trying to sell them on dealing with the personality disorder is pretty much like saying, “Look, an awful lot about the way you think and respond to things is kind of messed up. But, never fear! Together we can bulldoze your personality and how you think, feel and behave, pour a new slab, and then we’ll rebuilding you from the ground up. You’ll learn new ways of thinking, feeling and behaving.”

Even when it’s dressed up in tactful, compassionate psychological language, that, my friend, is a very hard sell indeed.

Dr. Lori Puterbaugh

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

Personal Responsibility and Mental Health

This is another reflection on the Florida Adlerian Society’s annual conference last Friday. One of the primary speakers emphasized the role of personal responsibility in mental health. I can imagine, taken out of context, how brutal that might sound. “Are we now blaming victims and ill people for their woes?” the person exposed to just that sound bite might wonder. “Is that what mental health professionals believe?

The short answer is no, that’s not what we believe.

Embracing free will and the dignity of each person, however, ineluctably leads one to emphasize the role of personal responsibility in how one deals with what happens in life. This isn’t something new: it is ancient philosophy dressed up in psychotherapy clothes. So, while someone may suffer terrible misfortunes outside of their control, the impetus to decide what to do about it is within them. Seek help, or sink into despair? Reach up to grasp a hand, or reach out for a bottle, or needle, or some other vial of trouble?

Sometimes people do have some personal responsibility for what happens, and indulge in magical thinking in which bad things just randomly happen to them. I recall a person I met many years ago who got into trouble for buying drugs. He complained about the injustice of the level of trouble; he didn’t mean to do it. It just happened. (I’m pretty much quoting here.) I asked, how do you buy drugs by accident? How do you take a peaceful stroll around your neighborhood and accidentally end up lurking behind a shopping center chatting with the type of entrepreneurs who set up shop near dumpsters and concrete walls? Acting like there is no personal responsibility means that there is no effort to make things better. It’s just a lot of bad luck, from his perspective; no reason to change because you can’t change “luck.”

Often, though, human suffering is due to others’ actions. Just the same, an adult has some power to effect change. The responsibility is not for others’ bad actions, but to take some sort of action to help oneself. Sometimes people evade taking responsibility to make change because it will be uncomfortable, or embarrassing, or mean that they have to admit that at some earlier point they were wrong. Breaking off a destructive friendship or leaving a toxic work environment can be very challenging for a host of reasons, and leaving an abusive relationship can be dangerous. Reach out and get help. If the first, or second, or third person you go to for help is clueless – keep looking for the right help.

Typically, people do things that undercut happiness and health in some way and evade responsibility. People have habits that cause insomnia, for example, and complain, as if poor sleep side-tackled them in the hallway due to no fault of their own. We take on extra activities and complain about being too busy. People fail to set limits with their kids and then yell and throw consequences around when their children are irresponsible, disrespectful and unpleasant to be around. People make choices all day, often on auto-pilot, and a great many of us are prone to griping about all sorts of situations that result, as if stuff just happens without cause. Yes, of course, sometimes, stuff does happen…but, if you’re always five minutes late…that’s you. Not the traffic, not the cat, not the dog…it’s you. If your friends are inconsiderate, that’s not your fault, but it is your problem if you keep tolerating it. If you do tolerate it, then take responsibility for it and stop complaining. “Yes, good old Joe is always late but that’s just him; it’s not personal.” You’ve decided to accept it. Stop griping. If you can’t stop griping, you haven’t accepted it. If you can’t accept it, then do something: leave when he’s late. Put your foot down. Tell him off. Lie about what time you’re meeting and get there late yourself (it might work, once). Whatever; if you’re not prepared to do something about it then face that you have decided to let Joe be chronically late without regard for your preferences or schedule because you have decided tolerating it beats the alternatives you’ve identified of annoying Joe or losing his friendship.

Narrowing it down to mental health, whatever a person is suffering, help is available. How one lives is always part of healing. Proper amounts of exercise, sleep and nutrition are part of it, and things for which most people can take some responsibility. Seeking right guidance requires making choices. Unless you belong to a professional mental health association, your friends might not be the best source of professional advice on the specific strategies, to, for example, use mindfulness training, exercise and specific cognitive therapy techniques to rewire your brain and reduce obsessive-compulsive symptoms. You get to choose. That’s not blaming you for your suffering, but it is saying that you have the freedom, responsibility, and capacity to move towards healing.


Dr. Lori Puterbaugh

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

Cognitive Behavioral Therapy: So Much More than Positive Thinking

It’s more than just positive thinking

A smart, thoughtful person mentioned the other day, in conversation, that Cognitive Behavioral Therapy (CBT) seems to be just “the power of positive thinking.” That’s probably what it sounds like when it gets boiled down to a sound bite…but in reality, it’s so much more. There are many excellent resources out there, so I won’t attempt to tackle the whole topic here. A brief example, though, on the difference between CBT and simple positive thinking, might help.

In CBT, we are indeed looking for patterns of negative thinking. These are identified, and then we dig down to the underlying thoughts. From there, the challenging and reforming of particular thoughts begins. Then comes the hard work of rehearsing those new thoughts.

Consider, for example, an adult who is very anxious about grades in college. This student is up late studying, preoccupied with grades, and anxious to the point of headaches and nausea before tests. The student feels terrible, of course. The top layer of thinking probably includes themes such as, “I have to do well,” or, “This is too important to fail.” The level of distress the client feels, though, seems out of proportion; the client is sick and nauseated over A- or B+ grades. Digging deeper, the client turns out to have buried beliefs such as, “Perfect or failure – no in-between,” or, “Hero or zero,” or, “No one loves a loser.” Thus, the A- feels like a failure and even a threat to love and security. Those aren’t conscious thoughts: no reasonable grownup thinks, “Oh, no one can love me because I got an A-!” It’s more of a personal belief, often acquired early in life, which became the background to many experiences.

You can see that trying to be “positive” about the top layer thoughts might seem silly: “Oh, it’s fine to fail,” or, “It’s OK for me to not do well.” The client cannot buy into that. However, a deeply held belief – that one is either perfect or a complete and utter failure – merits serious attention, and probably underlies many difficulties for this client. Thus CBT starts it work – which is much more complex than presented here – by seeking the foundational troubling beliefs that are leading to the negative thinking.

As I noted – this is a cursory glance at one aspect of CBT. It is a well-researched method of treating anxiety, OCD, depression, and other difficulties. If it seems as if it might be helpful for you, please see appropriate professional guidance.

Dr. Lori Puterbaugh

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.