Spotlight on Avoidance, Jenny Peetoom, RPsych.

OCD is named for two of its most prominent symptoms: obsessions – those intrusive unwanted thoughts or images that lead a person to feel anxiety or distress, and compulsions – the repetitive, time-consuming thoughts or actions a person engages in to reduce the anxiety or distress from unwanted thoughts. Reassurance seeking is another symptom where, like a compulsion, a person seeks reassurance from others to bring down anxiety or distress that results from an obsession. There is one component of OCD that is less often talked about and sometimes missed in the assessment and treatment of this disorder. Hello Avoidance.

In day-to-day life avoidance is an adaptive behaviour that helps keep us safe. When we see an icy patch on a walking path we avoid it and reduce our risk of falling. If we hear loud threatening sounds in the bushes, we give the area a wide berth to keep ourselves safe from potential harm. Sometimes we draw on avoidance in ways that may initially feel helpful but can become detrimental. Do poorly on a chemistry test and we may have an urge to avoid the next class, so we don’t have to experience disappointment. Say or do something embarrassing at a party and our minds may tell us to stay home so this doesn’t happen again. In these situations, avoidance helps keep us from feeling uncomfortable but will impede our goals of passing a chemistry course or making new friends.

Avoidance in OCD is similarly helpful in the moment but ultimately detrimental to recovery. Avoidance acts to “protect” the person from situations that may trigger the obsession, the distress, and the resulting compulsive urge. For someone who lives with OCD, avoidance may seem like a welcome reprieve from an unrelenting distressing cycle. Not going to the places or being around the things that trigger the intrusive thoughts means the person doesn’t have to expend energy feeling distressed or doing ritualized behaviours. A win… right?

Not exactly. As with all things OCD, the more you engage in an OCD driven behaviour, the more you feel you mustengage in an OCD driven behaviour. Engage in a compulsive behaviour today, and tomorrow OCD will ask you to do it twice “just to be sure”. Avoid hospitals because of intrusive thoughts about germs – soon you may be avoiding all public places! Avoid being in social gatherings because of an intrusive thought about yelling obscenities – soon you may be avoiding people all together! OCD driven avoidance often leads to more narrow, restrictive living.

Another way avoidance is problematic is it may trick you or your therapist into believing you have mastered your OCD when really what you mastered is how to avoid activating your OCD. Used to engage in compulsive washing in response to touching a sticky substance but don’t anymore? Ask yourself – are you ever in contact with sticky substances these days? Feeling like you have a solid lock on your unwanted thoughts about hitting someone with your car – when is the last time you drove?

As practitioners it is important that in assessing and treating OCD, we remember to be curious about avoidant behaviours and how they may be masking symptom severity and interfering with effective treatment. As people living with this disorder, it is important to be honest about our avoidant behaviours and encourage ourselves to avoid avoiding!

Jenny Peetoom, RPsych.